What is the role of steroids, such as prednisone (corticosteroid), in treating radiculopathy?

Steroids for Radiculopathy

Direct Recommendation

Oral steroids (prednisone 50-60 mg tapered over 10-15 days) provide modest short-term benefit for acute radiculopathy with radicular pain below the knee, but should NOT be used for non-radicular back pain alone. 1, 2

Oral Systemic Steroids

Evidence for Lumbar Radiculopathy

• A 2015 randomized controlled trial (n=269) demonstrated that oral prednisone (tapering 15-day course: 60mg/40mg/20mg for 5 days each) produced a statistically significant but modest 6.4-point improvement in Oswestry Disability Index at 3 weeks compared to placebo (P=0.006). 2
• However, pain reduction was minimal and not statistically significant (0.3 points on 0-10 scale at 3 weeks, P=0.34), indicating functional improvement without substantial pain relief. 2
• The benefit persisted at 1 year with 7.4-point greater ODI improvement (P=0.005), though pain differences remained non-significant. 2
• Adverse events occurred significantly more frequently with prednisone (49.2% vs 23.9%, P<0.001), including insomnia, nervousness, and increased appetite. 1, 2

Evidence for Cervical Radiculopathy

• A randomized trial of cervical radiculopathy showed that prednisolone 50 mg/day for 5 days (tapered over following 5 days) produced significantly greater improvement in both Neck Disability Index (35.7 vs 12.9, P<0.001) and pain scores (4.4 vs 1.6, P<0.001) compared to placebo. 3
• Clinical improvement occurred in 75.8% of prednisolone-treated patients versus 30% of placebo patients (P<0.001). 3

Clear Contraindications

• The American College of Physicians explicitly recommends AGAINST systemic corticosteroids for chronic low back pain, as multiple trials consistently found no differences between steroids and placebo. 1
• Six trials found no benefit for radicular low back pain in general populations (moderate strength evidence), though specific subgroups may respond. 1
• Systemic steroids are NOT recommended for non-radicular back pain, with high-quality evidence showing no benefit over placebo. 1

Epidural Steroid Injections

When to Consider

• Epidural steroid injections should ONLY be considered for patients with true radicular pain (pain radiating below the knee for lumbar, dermatomal arm pain for cervical) with MRI-confirmed nerve root compression who have failed at least 4-6 weeks of conservative therapy including physical therapy, NSAIDs, and activity modification. 4, 1
• The American Society of Anesthesiologists strongly recommends epidural steroid injections specifically for radicular pain or radiculopathy, NOT for axial back pain from facet arthropathy or mechanical causes. 4

Absolute Requirements Before Injection

• MRI must demonstrate nerve root compression that anatomically correlates with the clinical radicular symptoms. 4
• Minimum 4-6 weeks of failed conservative treatment must be documented, including physical therapy, NSAIDs, and oral medications. 4, 1
• Fluoroscopic guidance is mandatory for all epidural injections to ensure proper needle placement and minimize complications. 4
• Pain must radiate below the knee (lumbar) or follow a dermatomal pattern in the arm (cervical) to meet radicular criteria. 4

When NOT to Perform Epidural Injections

• The American Academy of Neurology explicitly recommends against epidural steroid injections for non-radicular low back pain, as evidence is limited. 4, 1
• The 2025 BMJ guideline provides a strong recommendation against epidural injections for chronic axial spine pain, stating "all or nearly all well-informed people would likely not want such interventions." 4
• Do NOT repeat epidural injections unless the initial injection provided at least 50% pain relief lasting at least 2 weeks (preferably 2 months). 4

Technique and Safety

• Transforaminal epidural injections carry higher risk than interlaminar approaches and require specific discussion of complications including dural puncture, insertion-site infections, cauda equina syndrome, sensorimotor deficits, discitis, epidural granuloma, retinal complications, and rare catastrophic events including paralysis and death. 4
• Shared decision-making must include explicit discussion of these potential serious complications before proceeding. 4
• Epidural injections must be part of a comprehensive multimodal treatment program including physical therapy, patient education, psychosocial support, and oral medications—not used as isolated therapy. 4, 1

Clinical Algorithm

Step 1: Confirm True Radiculopathy

• Verify pain radiates below the knee (lumbar) or follows dermatomal pattern in arm (cervical). 4
• Document objective neurological findings (sensory changes, motor weakness, reflex changes, positive straight leg raise). 4
• Obtain MRI showing nerve root compression that correlates anatomically with symptoms. 4

Step 2: Conservative Treatment First

• Initiate 4-6 weeks of conservative therapy: physical therapy, NSAIDs, activity modification, and patient education. 4, 1
• For acute severe radiculopathy, consider short course oral prednisone (50-60 mg tapered over 10-15 days) while continuing conservative measures. 3, 2
• Counsel patients that oral steroids provide modest functional improvement but minimal pain relief, with nearly 50% experiencing adverse effects. 2

Step 3: Reassess After Conservative Treatment

• If symptoms persist after 4-6 weeks of conservative treatment AND MRI confirms nerve root compression, epidural steroid injection may be considered. 4, 1
• If pain is primarily axial (non-radicular), do NOT proceed with epidural injection—consider alternative diagnoses such as facet-mediated pain or sacroiliac joint dysfunction. 4

Step 4: Epidural Injection Decision

• Perform shared decision-making discussion including all potential complications. 4
• Ensure fluoroscopic guidance will be used. 4
• Confirm injection is part of comprehensive multimodal treatment plan, not isolated intervention. 4
• Document that patient understands repeat injections are only appropriate if initial injection provides ≥50% relief for ≥2 weeks. 4

Critical Pitfalls to Avoid

• Do NOT use systemic steroids for chronic low back pain or non-radicular pain—this is explicitly contraindicated by guidelines. 1
• Do NOT perform epidural injections without fluoroscopic guidance—this is a mandatory safety requirement. 4
• Do NOT repeat epidural injections without documented objective benefit (≥50% relief for ≥2 weeks) from prior injection. 4
• Do NOT use epidural injections as a "bridge to surgery" or delay tactic—they should be part of comprehensive pain management with goal of functional improvement. 4
• Do NOT ignore alternative pain generators (facet joints, sacroiliac joints, hip pathology) when physical examination suggests their involvement. 4
• Be aware that the number needed to harm for oral prednisone is only 4, meaning 1 in 4 patients will experience adverse effects. 1

Special Circumstance: Malignant Spinal Cord Compression

• High-dose dexamethasone (16-96 mg/day, sometimes with IV bolus) should be given immediately for malignant spinal cord compression—this is a distinct indication separate from degenerative radiculopathy. 1