Oral Prednisone for Low Back Pain Before Surgery: Not Recommended
You were correct to advise against prednisone—systemic corticosteroids are not recommended for low back pain with or without radiculopathy, and the upcoming surgery is an additional reason to avoid them. 1, 2, 3
Why Corticosteroids Don't Work for Low Back Pain
Evidence Against Efficacy
Multiple high-quality trials consistently show no clinically meaningful benefit from systemic corticosteroids (oral or intramuscular) for acute non-radicular low back pain compared to placebo. 1, 4
For radicular pain (sciatica), six trials found no differences between corticosteroids and placebo in pain relief, and two trials showed no effect on the likelihood of requiring spine surgery. 1, 4
Even when modest statistical improvements are detected (as in one large trial showing 6.4-point ODI improvement at 3 weeks), pain scores themselves show no significant difference (only 0.3 points on a 0-10 scale at 3 weeks, not reaching clinical significance). 5
The American College of Physicians explicitly states that systemic corticosteroids should not be used for low back pain based on this consistent evidence of lack of efficacy. 2, 3
Harm Profile
While not causing serious complications in short courses, prednisone does cause significant adverse effects:
Number needed to harm is only 4—meaning for every 4 patients treated, one will experience an adverse event. 4
Common side effects include insomnia (26% vs 10% placebo), nervousness (18% vs 8%), increased appetite (22% vs 10%), and overall adverse events (49% vs 24%). 1
Patients on prednisone seek additional medical treatment more frequently (40% vs 18% placebo), suggesting the medication may complicate rather than improve the clinical course. 6
Surgical Timing Considerations
Your concern about upcoming surgery adds another layer:
Corticosteroids can impair wound healing, increase infection risk, and affect glucose control—all relevant perioperative concerns even with short courses. 4
Since trials show no reduction in the need for surgery with corticosteroid use, there is no benefit to justify these perioperative risks. 1, 5
What to Offer Instead
First-Line Pharmacologic Options
NSAIDs provide small to moderate pain improvements and should be your first-line medication if not contraindicated. 2, 3
For radicular symptoms specifically, NSAIDs combined with gabapentin target both inflammatory and neuropathic pain components. 3
Skeletal muscle relaxants combined with NSAIDs show consistent short-term benefit for acute low back pain. 4
Non-Pharmacologic Management
Advise the patient to remain active—bed rest delays recovery and activity restriction is counterproductive. 2, 3
Provide evidence-based education about the generally favorable natural history of low back pain, with high likelihood of substantial improvement in the first month. 1
Consider referral for supervised exercise therapy, spinal manipulation, or acupuncture if symptoms are subacute or chronic. 3, 4
Critical Pitfall to Avoid
Despite corticosteroids' anti-inflammatory properties, clinical trials consistently demonstrate they do not provide meaningful pain relief for any type of low back pain—whether radicular or non-radicular, acute or chronic. 2, 4, 7 This counterintuitive finding reflects that the pathophysiology of most low back pain is more complex than simple inflammation, and the risks outweigh the minimal or absent benefits.