What is the role of oral corticosteroids (e.g. prednisone) in the management of a patient with spondylolisthesis, particularly in the context of acute inflammatory episodes or severe pain?

Oral Corticosteroids for Spondylolisthesis

Oral corticosteroids should NOT be used for spondylolisthesis—there is no evidence supporting their efficacy for axial spine pain, and guidelines explicitly recommend against long-term systemic glucocorticoids for axial disease. 1

Evidence Against Oral Corticosteroids

The most recent and highest-quality guidelines addressing spondyloarthropathies (which share inflammatory mechanisms with some spondylolisthesis presentations) are clear:

• No published studies exist evaluating oral corticosteroid treatment for axial spine conditions like spondylolisthesis 1
• The ASAS-EULAR 2016 guidelines explicitly state that "patients with axial disease should not receive long-term treatment with systemic glucocorticoids" regardless of dose 1
• Even short-term high-dose systemic glucocorticoids (50 mg/day) showed only "very modest effect" on axial symptoms in related conditions 1

What Actually Works for Spondylolisthesis

First-Line Treatment

• NSAIDs at maximum tolerated anti-inflammatory doses are the cornerstone of pharmacologic management 1, 2, 3
• Physical therapy and supervised exercise programs should be initiated immediately 2, 3

Second-Line Options for Persistent Pain

• Epidural steroid injections (not oral steroids) provide pain relief in degenerative spondylolisthesis, with better outcomes than isthmic types (72% vs 54% pain relief) 4
• Transforaminal epidural injections at the level of spondylolisthesis can provide pain relief lasting an average of 181 days in degenerative cases 4
• However, epidural injections show little effect on long-term clinical outcomes or surgical crossover rates over 4 years 5

When Conservative Treatment Fails

• Surgical intervention (decompression with or without fusion) is appropriate for well-selected patients who fail 3-6 months of conservative management 2, 6, 3
• Fusion alone is indicated for mechanical lumbar symptoms; decompression plus fusion is needed when nerve root compression is documented 6

The Role of Corticosteroids (If Any)

The only appropriate corticosteroid use in spondylolisthesis is:

• Local epidural steroid injections for radicular pain or neurogenic claudication 2, 4, 3
• Never oral/systemic corticosteroids for the axial spine component 1

Critical Pitfalls to Avoid

• Do not prescribe oral prednisone for spondylolisthesis pain—this lacks evidence and violates guideline recommendations for axial spine disease 1
• Do not confuse the FDA indication for prednisone in "ankylosing spondylitis" 7 with spondylolisthesis—these are completely different conditions despite similar-sounding names
• Recognize that while prednisone is FDA-approved for "acute and subacute bursitis" and "acute nonspecific tenosynovitis" 7, spondylolisthesis is a structural/mechanical spine problem, not an acute inflammatory soft tissue condition

Alternative Analgesics

If NSAIDs are contraindicated or insufficient:

• Paracetamol up to 4g/day can be considered as an alternative or complement 1
• Opioid-like analgesics may be used only for residual pain after all other treatments have failed 1