What short oral corticosteroid regimen is appropriate for an adult with acute severe lumbar radiculopathy pain and no contraindications to systemic steroids?

Oral Corticosteroids for Lumbar Radiculopathy: Not Recommended

Do not prescribe a short course of oral corticosteroids for lumbar radiculopathy pain, as multiple high-quality guidelines and trials consistently demonstrate no clinically meaningful benefit over placebo. 1, 2, 3

Why Steroids Don't Work Despite Seeming Logical

• 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, 2, 3

• Six trials with moderate-strength evidence found no differences between systemic corticosteroids and placebo in pain relief for radicular low back pain. 1, 3

• The largest high-quality trial (n=269) showed that a 15-day prednisone taper (60mg→40mg→20mg, total 600mg) produced only a 0.3-point greater pain reduction on a 0-10 scale at 3 weeks compared to placebo—a difference that is not clinically meaningful. 4

• While that same trial showed modest 6.4-point improvement in disability scores at 3 weeks, this small benefit does not justify routine use given the lack of pain relief and adverse event profile. 4

What Actually Works: The Evidence-Based Algorithm

First-Line Treatment

• Start with NSAIDs at maximum tolerated dose as they provide small to moderate improvements in pain intensity for acute radicular pain. 2, 5

• No specific NSAID is superior to another; prescribe whichever is best tolerated and has the fewest contraindications for your patient. 5

Second-Line: Add Gabapentin

• Combine NSAIDs with gabapentin to target both inflammatory and neuropathic pain components of radiculopathy. 1, 2

• Gabapentin has fair evidence for effectiveness specifically in radiculopathy, though benefits are small and short-term. 1

Third-Line: Consider Skeletal Muscle Relaxants

• If muscle spasm is prominent, add a skeletal muscle relaxant to the NSAID regimen for short-term pain relief. 1, 5

• Be aware that skeletal muscle relaxants cause sedation in most patients. 1

Harms of Oral Steroids You're Exposing Patients To

• A 15-day prednisone course causes adverse events in 49% of patients versus 24% with placebo (number needed to harm = 4). 3, 4

• Common adverse effects include insomnia, nervousness, increased appetite, hyperglycemia, and facial flushing. 3, 4

• These harms occur without meaningful clinical benefit for pain relief. 2, 4

The One Exception: Epidural Steroids (Not Oral)

• Epidural corticosteroid injections (not oral steroids) may be considered for severe, refractory radicular pain, as they deliver medication directly to the site of inflammation. 3, 6

• Epidural injections produce a small reduction in leg pain (MD -4.93 on 0-100 scale) and disability (MD -4.18 on 0-100 scale) at short-term follow-up, though these effects may not be clinically important to many patients. 6

• Epidural dexamethasone 4-8mg may be more effective for disc herniation than for stenotic lesions. 3

Critical Pitfall to Avoid

Do not prescribe a "steroid dose pack" or prednisone taper for routine lumbar radiculopathy simply because it seems like it should work or because patients expect it. The anti-inflammatory properties of corticosteroids do not translate to meaningful pain relief in this condition, as demonstrated by multiple high-quality trials. 2, 4, 7

Counsel Patients on Natural History

• Advise patients to remain active and avoid bed rest, as activity restriction delays recovery. 2

• Most acute radicular pain improves over time with NSAIDs and activity modification alone. 5