Is prednisone (a corticosteroid) indicated for an adult patient with a history of inflammatory conditions and back pain, undergoing Magnetic Resonance Imaging (MRI) and L5-S1 spinal fusion surgery?

Prednisone Use Before MRI and L5-S1 Fusion Surgery

Direct Recommendation

Prednisone should be stopped or dose-minimized before elective L5-S1 fusion surgery whenever possible, as preoperative corticosteroid use significantly increases the risk of postoperative infectious complications and anastomotic leaks. 1

Preoperative Corticosteroid Management

Evidence Against Preoperative Steroids

• Patients undergoing spinal fusion while on corticosteroids have an increased risk of postoperative infectious complications, with the greatest risks occurring at doses of 40 mg prednisolone or higher 1
• Doses greater than 20 mg prednisolone show increased complication rates, though the difference between >20 mg versus ≤20 mg is less pronounced than at higher doses 1
• For elective surgery, corticosteroids should be stopped or brought to the lowest manageable dose without clinical deterioration 1

Perioperative Steroid Coverage

• If a patient is currently taking corticosteroids and cannot be weaned before surgery, they should receive intravenous hydrocortisone in equivalent dosage perioperatively until oral prednisolone can be resumed 1
• The conversion is prednisolone 5 mg = hydrocortisone 20 mg (or methylprednisolone 4 mg) 1
• There is no value in increasing steroid dosage to cover perioperative stress, as demonstrated in randomized trials 1
• Anesthetists typically give a single steroid dose prior to induction (such as dexamethasone 4 mg IV or IM) for patients taking more than 5 mg prednisolone 1

Specific Concerns for L5-S1 Fusion

Postoperative Radiculitis Risk

• Methylprednisolone use is an independent predictor of postoperative radiculitis after L5-S1 ALIF, with an odds ratio of 6.032 (95% CI: 1.670-25.568) 2
• This represents a paradoxical finding where perioperative steroid administration actually increases the risk of nerve root inflammation rather than preventing it 2
• Postoperative radiculitis after L5-S1 fusion typically resolves within 3 months but causes significant short-term morbidity 2

Alternative Approaches to Inflammation Management

• Steroids have not been proven to provide better clinical outcomes for acute low back pain in the perioperative setting 3
• Local steroid use in anterior cervical procedures has shown benefit for preventing dysphagia, but this evidence does not extend to lumbar fusion 3
• The use of hydrogel sealant to shield the exiting nerve root has been shown to decrease radiculitis incidence from 20.4% to 5.4%, representing a more effective strategy than systemic steroids 4

MRI Considerations

Timing of MRI Relative to Steroid Use

• MRI should not be routinely obtained in stable patients, as it does not improve clinical outcomes and may lead to overtreatment 1
• For patients with active inflammatory conditions requiring MRI, the imaging should focus on documenting neural compression and instability rather than inflammatory changes 1
• Follow-up MRI performed <4 weeks after baseline may falsely suggest progressive infection despite clinical improvement, particularly when considering vertebral body and disc space findings 1

MRI Interpretation Caveats

• Bone marrow edema lesions on MRI may occur in individuals without axial spondyloarthritis and may not represent true inflammation 1
• MRI findings of degenerative changes often correlate poorly with symptoms, and the presence of disc degeneration alone does not mandate surgical intervention 5
• Discography combined with MRI has limited predictive value, with only 50% success rates in patients with normal MRI findings versus 75% in those with abnormal MRI and abnormal discography 6

Clinical Algorithm for Steroid Management

For Patients Currently on Steroids:

1. Attempt to wean to lowest possible dose (ideally <20 mg prednisolone equivalent) over several weeks before elective surgery 1
2. If weaning is not possible due to underlying inflammatory condition, continue current dose but plan for perioperative IV hydrocortisone coverage 1
3. Avoid methylprednisolone specifically in the perioperative period for L5-S1 fusion due to increased radiculitis risk 2
4. Resume oral prednisolone postoperatively and implement standardized taper protocol to avoid inappropriate prolongation 1

For Patients Not on Steroids:

1. Do not initiate steroids preoperatively for prophylaxis against inflammation or radiculitis 2, 3
2. Consider alternative strategies for nerve root protection, such as hydrogel sealants during TLIF procedures 4
3. Rely on multimodal pain management protocols rather than systemic steroids for postoperative pain control 4

Critical Pitfalls to Avoid

• Do not assume steroids will prevent postoperative radiculitis—evidence shows they may increase this risk 2
• Avoid obtaining MRI solely to "confirm" disease activity in stable patients, as this does not change management and may lead to unnecessary treatment escalation 1
• Do not continue high-dose steroids (>20 mg prednisolone) into the perioperative period without attempting dose reduction 1
• Recognize that imaging abnormalities (Modic changes, disc degeneration) do not automatically indicate need for steroids or predict surgical success 5, 6