Steroids Are Not Recommended for Uncomplicated Acute Low Back Pain
Systemic corticosteroids should not be used for acute low back pain with or without radiculopathy, as multiple high-quality trials consistently demonstrate no benefit over placebo. 1, 2
Evidence Against Systemic Corticosteroids
The evidence is clear and consistent across multiple guidelines:
Three small, high-quality randomized controlled trials found that systemic corticosteroids (given parenterally as a single injection or as a short oral taper) provided no clinically significant benefit compared to placebo for acute sciatica. 1
For patients with acute low back pain and a negative straight-leg-raise test, a single intramuscular injection of methylprednisolone (160 mg) showed no difference in pain relief through 1 month compared to placebo. 1
The American College of Physicians and American Pain Society explicitly recommend against systemic corticosteroids for low back pain with or without sciatica based on high-quality evidence of lack of efficacy. 2, 3
The most recent 2025 BMJ guideline on interventional procedures issued a strong recommendation against epidural injection of steroids for both chronic axial and radicular spine pain. 1
What Should Be Used Instead
First-line treatment consists of:
NSAIDs (ibuprofen 400-800 mg three times daily, naproxen 500 mg twice daily, or diclofenac 50 mg twice daily) provide moderate short-term efficacy for pain relief. 1, 2, 4
Acetaminophen is an alternative if NSAIDs are contraindicated or not tolerated. 1, 2
Advice to remain active rather than bed rest, with reassurance about the self-limited nature of acute low back pain. 1, 2
Second-line options if NSAIDs are insufficient:
Skeletal muscle relaxants (such as cyclobenzaprine) can be added for short-term use (≤1-2 weeks) for modest additional pain relief, though they cause sedation and dizziness. 1, 2
Spinal manipulation is the only non-pharmacologic intervention with proven short-term benefit for acute low back pain, providing small-to-moderate improvements. 2
For Radicular Pain Specifically
If true radiculopathy/sciatica is present (positive straight-leg raise, dermatomal distribution):
Gabapentin (titrated to 1200-3600 mg/day in divided doses) shows small to moderate short-term benefits specifically for radicular pain, though evidence quality is mixed. 2, 3
Systemic corticosteroids remain ineffective even in this subgroup, contrary to what might be expected. 1, 2
Critical Pitfalls to Avoid
Do not order imaging in the first 4-6 weeks unless red-flag symptoms are present (cauda equina syndrome, progressive motor deficits, fever, unexplained weight loss, history of cancer). 1, 2
Do not prescribe muscle relaxants beyond 1-2 weeks, as no evidence supports longer-term use and risks of tolerance and dependence increase. 1, 3
Do not use benzodiazepines for back pain, as they have high abuse potential and no proven efficacy for radiculopathy. 2, 3
Reassess within 2-4 weeks and consider alternative approaches if inadequate response, including possible referral for physical therapy or specialist evaluation. 1, 2
Why Steroids Don't Work
The lack of efficacy may relate to the pathophysiology of acute low back pain:
Most acute low back pain is self-limited and resolves spontaneously within 4-6 weeks regardless of treatment. 1
The majority of disc herniations show spontaneous reabsorption by 8 weeks after symptom onset, making anti-inflammatory interventions largely irrelevant to natural history. 1, 2
Preclinical studies suggest that mineralocorticoid receptor activation in the dorsal root ganglion may have pro-inflammatory effects that oppose glucocorticoid effects, potentially explaining limited steroid efficacy. 5