A 62-year-old man with chronic lumbar back pain asks you whether steroids might help alleviate his worsening back pain. For 6 months he has had non-radiating lower back pain that has not responded to symptomatic treatment with acetaminophen, NSAIDS, and antispasmodic agents. Physical therapy exercises have also failed to relieve his symptoms. For the past week, he has had new onset of pain that intermittently radiates to the bilateral buttocks, lateral part of the legs and feet, and numbness with tingling on the lateral legs and dorsum of feet. He denies any saddle paresthesia or incontinence of the bladder or bowels.
On examination, he has a positive straight leg raise (Lasègue’s sign), no vertebral tenderness, and decreased strength in foot dorsiflexion. An MRI of the lumbar and sacral spine reveals focal disc protrusion and foraminal stenosis at the level of L5-S1, with moderate compression of the S1 nerve. (Sample MRI image above; click to enlarge; courtesy Loyola University Medical Education Network.)
Answer: C: An RCT shows that a short course of oral steroids modestly improves function but not pain.
WHAT’S THE EVIDENCE?
Oral steroids are commonly used to treat acute sciatica due to a herniated disk and have been included in some clinical guidelines as a treatment option. However, they had not been evaluated in an appropriately powered clinical trial until very recently.
A large clinical trial published in JAMA in 2015 looked at whether oral prednisone is more effective than placebo in improving function and pain among patients with acute sciatica. This randomized, double-blind, placebo-controlled study included patients with an Oswestry Disability Index (ODI) score of 30 or higher (range, 1-100), a herniated disk confirmed by MRI, and radicular pain for 3 months or less. None had previously received oral or epidural steroid injection.
- The prednisone-treated group showed an adjusted mean 6.4 point (95% CI, 1.9-10.9; P = .006) greater improvement in ODI scores at 3 weeks than the placebo group, and a mean 7.4 point (95%CI, 2.2-12.5; P = .005) greater improvement at 52 weeks.
- The prednisone-treated group showed an adjusted mean 0.3 point (95% CI, -0.4 to 1.0; P = .34) greater reduction in pain at 3 weeks and a mean 0.6-point (95% CI, -0.2 to 1.3; P = .15) greater reduction at 52 weeks.
- Overall, among patients with acute radiculopathy from a herniated lumbar disc, a short course of oral steroids, compared with placebo, resulted in modestly improved function and no improvement in pain.
OUTCOME OF THE CASE
It was thoroughly explained to the patient that the benefit of systemic steroids, if any, is modest and likely transient. He was informed that the interpretation of current evidence-based data for management of acute radiculopathy is confounded by issues such as the self-limited and often benign course of lumbosacral radiculopathy, environmental factors, and possible placebo effect.
The patient was ultimately treated with oral prednisone, 60 mg/d for 7 days without a taper, for acute lumbosacral radiculopathy refractory to other analgesics and lifestyle activity modification. This treatment yielded short-term relief.
1. Goldberg H, Firtch W, Tyburski M, et al. Oral steroids for acute radiculopathy due to a herniated disk: a randomized clinical trial. JAMA. 2015;313:1915-1923.