What is the recommended use of steroids for treating radiculopathy?

Steroid Use for Radiculopathy

Systemic corticosteroids (oral or IV) are NOT recommended for radiculopathy, as they provide no benefit over placebo and significantly increase adverse events; epidural steroid injections under fluoroscopic guidance are the evidence-based interventional option for patients with true radiculopathy who have failed 4-6 weeks of conservative therapy. 1, 2

Systemic Steroids: Not Recommended

• The American College of Physicians explicitly recommends against systemic corticosteroids for low back pain with or without sciatica, as six high-quality trials consistently demonstrated no difference from placebo in pain relief or functional improvement 1, 2
• Oral prednisone significantly increases adverse events including insomnia, nervousness, and increased appetite, while providing no therapeutic benefit 2
• Systemic corticosteroids do not reduce the likelihood of requiring spine surgery 2
• Despite one small randomized trial showing oral prednisolone reduced pain in cervical radiculopathy 3, this contradicts the stronger guideline evidence from the American College of Physicians that applies to both lumbar and cervical radiculopathy 1, 2

Epidural Steroid Injections: Evidence-Based Alternative

Patient Selection Criteria

All of the following must be documented before proceeding with epidural injection:

• True radiculopathy with pain radiating below the knee (for lumbar) or into the arm (for cervical), not just axial back or neck pain 4, 2, 5
• MRI evidence of nerve root compression that anatomically correlates with the clinical symptoms and dermatomal distribution 4, 2
• Failed conservative management for minimum 4-6 weeks, including physical therapy, NSAIDs, and activity modification 4, 2
• Clinical examination findings such as positive straight leg raise, dermatomal sensory changes, or motor weakness consistent with the imaging findings 4, 2

Critical Exclusions

• Do not perform epidural injections for non-radicular low back pain, as the American Academy of Neurology explicitly recommends against this practice due to lack of efficacy 4, 2, 5
• Do not use epidural injections for mechanical back pain from spondylosis without true radiculopathy, as this does not meet medical necessity criteria 5

Technical Requirements

• Fluoroscopic guidance is mandatory for all epidural injections to ensure proper needle placement and reduce complications 4, 2, 6
• Contrast confirmation should be obtained to verify epidural spread and rule out intravascular injection 4
• Nonparticulate steroids (dexamethasone) should be used as first-line agents, particularly for cervical and lumbar transforaminal approaches, given equivalent efficacy to particulate steroids but lower risk of catastrophic neurological complications 7

Efficacy Evidence

• Level I evidence supports epidural injections with local anesthetic and steroids for radiculopathy, with significant pain relief and functional improvement at 6-month follow-up 6
• Level I-II evidence supports local anesthetic alone (without steroids) for epidural injections, though there is a tendency toward better outcomes when steroids are added 6
• The American Society of Anesthesiologists strongly recommends epidural steroid injections specifically for radicular pain or radiculopathy as part of a multimodal treatment regimen 4, 2

Repeat Injection Criteria

• Repeat therapeutic epidural injection is only appropriate if the initial injection provided at least 50% pain relief lasting at least 2 months 4
• Do not repeat injections based solely on patient request without objective evidence of prior benefit 4

Common Pitfalls to Avoid

• Do not skip the 4-6 week conservative therapy trial before considering epidural injections, as this is a fundamental requirement 4, 2
• Do not perform epidural injections without fluoroscopy, as blind techniques have unacceptably high rates of incorrect needle placement 4, 2
• Do not use systemic steroids (oral or IV) as they cause harm without benefit 1, 2
• Do not ignore alternative pain generators such as sacroiliac joint pathology or facet-mediated pain when physical examination suggests their involvement 4

Shared Decision-Making Requirements

Patients must be counseled about potential complications before epidural injection:

• Dural puncture, insertion-site infections, cauda equina syndrome 4, 2
• Sensorimotor deficits, discitis, epidural granuloma 4
• Retinal complications and rare catastrophic neurological injury (particularly with transforaminal approach) 4, 5
• Transforaminal injections carry higher risk than interlaminar approaches and require specific discussion of these elevated risks 4

Multimodal Context

• Epidural injections must be part of a comprehensive pain management program that includes physical therapy, patient education, psychosocial support, and appropriate oral medications 4, 2
• Epidural injections are not a bridge to inevitable surgery but rather a component of comprehensive conservative management 4