Do Not Prescribe Systemic Corticosteroids for Sciatica
Systemic corticosteroids, including methylprednisolone (Solu-Medrol) bursts, should not be used for acute sciatica because high-quality guideline evidence consistently demonstrates no clinically meaningful benefit for pain relief or functional improvement. 1, 2
Why Corticosteroids Don't Work for Sciatica
The American College of Physicians explicitly states that systemic corticosteroids should not be used for low back pain with or without sciatica based on consistent evidence showing lack of efficacy. 1 This recommendation applies to all forms of systemic administration—whether intravenous, intramuscular, or oral tapers. 1, 2
The Evidence Against Corticosteroids
Three high-quality randomized trials consistently showed no clinically significant benefit when systemic corticosteroids were given for acute sciatica, regardless of route of administration. 1
A single IV bolus of 500 mg methylprednisolone provided only transient improvement in leg pain within the first 3 days, but the effect size was small and did not persist beyond this brief period. 3 More importantly, IV glucocorticoids had no effect on functional disability or clinical signs of radicular irritation. 3
A 2019 multicenter trial comparing intravenous methylprednisolone (60 mg/day for 5 days) with placebo found no significant difference in leg pain between groups over the study period. 4
Despite their anti-inflammatory properties, corticosteroids do not provide meaningful pain relief for sciatica in clinical practice. 1
What You Should Prescribe Instead
First-Line: NSAIDs
- NSAIDs are the appropriate first-line pharmacologic therapy for sciatica, as they provide small to moderate improvements in pain intensity. 1, 2
- No specific NSAID is superior to another; prescribe the maximum tolerated dose of any NSAID. 2
- Moderate-quality evidence supports NSAIDs for reducing pain and improving disability scores. 2
Add Gabapentin for Neuropathic Component
- NSAIDs combined with gabapentin target both inflammatory and neuropathic components of radicular pain specifically. 1
Consider Muscle Relaxants if Spasm Present
- When NSAID monotherapy is insufficient and muscle spasm is present, adding a skeletal muscle relaxant provides moderate-quality evidence for short-term pain relief. 2
Non-Pharmacologic Essentials
- Advise patients to remain active and avoid bed rest, as activity restriction delays recovery. 1
- Most acute sciatica improves over time with NSAIDs and activity modification. 2
Critical Pitfall to Avoid
Do not prescribe a "burst-and-taper" prednisone or methylprednisolone regimen for routine sciatica, as it lacks supporting evidence and exposes patients to unnecessary corticosteroid risks including hyperglycemia, facial flushing, and gastrointestinal effects. 1, 2
When Corticosteroids Might Be Considered (Not Systemic)
The only scenario where corticosteroids have conditional support is locally administered epidural or nerve root injections for isolated radiculopathy—but this is a procedural intervention, not a systemic burst regimen. 1 Even then, the evidence quality is limited.