Level 1 (likely reliable) evidence
Lumbar disk herniation often presents with sciatica radiating from the lower back to the lower leg and foot. Although radiculopathic pain usually begins to resolve within 2 to 4 weeks with conservative management, the pain may persist for more than 1 year in up to 30% of patients. Systemic steroids are often prescribed as part of conservative management, but data on the efficacy of this approach is limited. A recent randomized trial compared oral prednisone against placebo for 15 days in 269 adults with acute radiculopathy due to lumbar disk herniation (JAMA. 2015;313:1915-1923). The steroid dosing regimen consisted of 20-mg capsules of prednisone given as 60 mg daily for 5 days, then 40 mg daily for 5 days, and then 20 mg daily for the final 5 days. Patients randomly assigned to the placebo group received capsules and a dosing schedule that appeared identical. Nonsteroidal anti-inflammatory drugs were prohibited for 3 weeks following randomization.
To be included in the trial, patients were required to have radicular pain for 3 months or less, a herniated disk confirmed by magnetic resonance imaging (MRI), and an Oswestry Disability Index (ODI) score of 30 or higher indicating at least moderate disability (mean ODI score, 51). The minimum clinically important difference was predefined as a 7-point difference in the ODI score between groups. At 3 weeks after randomization, the mean ODI score in patients randomly assigned to receive prednisone decreased by 19 points compared with 13.3 points for patients receiving placebo (P = 0.006). Prednisone was also associated with a greater number of patients achieving a reduction in ODI score of 50% or greater at this time point (33% vs. 19.8%, P = 0.01; number needed to treat [NNT], 8). By 52 weeks, the mean difference from baseline ODI scores was 37.8 points in the prednisone group and 30.4 points for the placebo group (P = 0.005). Prednisone did not improve pain scores at 3 or 52 weeks, but prednisone was associated with an increased risk of adverse events. At least one adverse event was reported in 49.2% of patients on prednisone and in 23.9% of patients on placebo (P < 0.001; NNH, 4). Insomnia, nervousness, and increased appetite were all significantly more common with prednisone, compared with placebo.
Treatment with prednisone resulted in a significantly greater proportion of patients with an improvement in their ODI scores of at least 50% at 3 weeks. Prednisone did not decrease pain or the risk of back surgery, and prednisone was associated with an increase in adverse events. Overall, these findings suggest that prednisone may improve disability in some patients with acute radiculopathy due to lumbar disk herniation but it does not improve pain status, and prednisone will result in some type of adverse effect in nearly half of patients. Benefits and risks seem closely balanced, and the decision to use steroids for this indication should be made on an individual basis.
Alan Ehrlich, MD, is a deputy editor for DynaMed, in Ipswich, Mass., and assistant clinical professor in Family Medicine, University of Massachusetts Medical School in Worcester.
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