Is a single dose of prednisone (corticosteroid) beneficial for a patient with acute on chronic back pain and muscle spasm?

Single-Dose Prednisone for Acute-on-Chronic Back Pain with Muscle Spasm

A single dose of prednisone provides no benefit for acute-on-chronic back pain with muscle spasm and should not be used. 1

Evidence Against Corticosteroid Use

The American College of Physicians guidelines explicitly state that systemic corticosteroids—whether given as a single intramuscular injection of methylprednisolone or a 5-day course of prednisolone—show no difference in pain or function compared with placebo in patients with acute low back pain. 1 This is based on low-quality evidence from multiple trials, but the consistency of findings across studies is notable.

For non-radicular back pain specifically (which includes muscle spasm without nerve root involvement), a 2022 Cochrane review found that systemic corticosteroids may actually be associated with slightly worse short-term pain outcomes. 2

A 2014 randomized controlled trial of 50 mg prednisone daily for 5 days in ED patients with musculoskeletal low back pain found:

• No difference in pain scores at 5-day follow-up 3
• No improvement in functional status or return to work 3
• More patients in the prednisone group sought additional medical treatment (40% vs 18%, a concerning finding suggesting possible harm or inadequate relief) 3

What Actually Works for Muscle Spasm

For acute back pain with muscle spasm, use skeletal muscle relaxants (SMRs) combined with NSAIDs instead. 1

Recommended Treatment Algorithm:

1. First-line: NSAID + Skeletal Muscle Relaxant

   • Moderate-quality evidence shows SMRs improve short-term pain relief at 2-4 and 5-7 days compared to placebo 1
   • Combination therapy (cyclobenzaprine + naproxen) produces less objective muscle spasm, less tenderness, and greater lumbosacral spine motion compared to NSAID alone 4
   • Recent evidence shows eperisone 50 mg three times daily + ibuprofen 400 mg twice daily results in 72.4% of patients achieving >50% pain reduction at 4 weeks, compared to 46.7% with ibuprofen alone 5

2. NSAID Selection

   • Moderate-quality evidence shows NSAIDs provide small improvement in pain intensity versus placebo 1
   • No specific NSAID is superior to another 1

3. Muscle Relaxant Considerations

   • Expect CNS side effects (drowsiness) with traditional agents like cyclobenzaprine 4
   • Eperisone may have fewer CNS effects while maintaining efficacy 6, 5
   • Adding a muscle relaxant to NSAIDs increases CNS adverse events (RR 2.44) but may reduce GI adverse events 1

Critical Distinction: Radicular vs Non-Radicular Pain

The only scenario where corticosteroids might have marginal benefit is radicular pain (sciatica with nerve root involvement), not muscle spasm. 2

Even in radicular pain, the benefit is minimal:

• Pain improvement of only 0.56 points on a 0-10 scale 2
• No reduction in need for surgery 2
• Effects are short-term only 2

For your patient with "acute-on-chronic back pain with muscle spasm" (which describes non-radicular mechanical pain), corticosteroids are ineffective. 1, 2, 3

Common Pitfall to Avoid

Do not confuse the lack of benefit in non-radicular back pain with the potential (though still modest) benefit in acute radiculopathy. The mechanism of muscle spasm is not primarily inflammatory, so anti-inflammatory corticosteroids are not the appropriate therapeutic target. 1