The efficacy of single-dose intravenous corticosteroids in reducing radicular low back pain
Date First Published:
April 13, 2020
Last Updated:
April 13, 2020
Report by:
Meredith Busman MD, Jason Seamon DO, EM Senior Resident, EM Faculty (Spectrum Health/Michigan State University Emergency Medicine Residency Program)
Search checked by:
Jeffrey Jones MD, Spectrum Health/Michigan State University Emergency Medicine Residency Program
Three-Part Question:
In [adults with acute radicular low back pain] is a [single-dose of intravenous corticosteroids compared to placebo] more effective in [reducing pain and disability].
Clinical Scenario:
A 55-year-old male with a history of hypertension, depression, and obesity presents to the Emergency Department with back pain that began 2 days ago after he was helping a friend move into a new apartment. He describes the pain as 10/10 in severity, radiating down his right leg and not improved with 600 mg of ibuprofen twice daily. He denies a history of similar back pain or traumatic injury but is requesting medication to relieve his pain so he can go back to work at a local manufacturing plant.
Search Strategy:
Medline 1966-04/20 using PubMed, Cochrane Library (2020), and Embase
Search Details:
[(exp low back pain OR exp sciatica OR exp radiculopathy) AND ( exp steroids OR exp adrenal cortex hormones OR exp corticosteroids OR exp methylprednisolone OR exp hydrocortisone OR exp dexamethasone OR exp glucocorticoids) AND (exp intravenous)]. Limit to English language.
Outcome:
47 studies were identified; two RCTs addressed the clinical question. One recent meta-analysis was also found but it provided no additional information.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Does a single dose of intravenous dexamethasone reduce symptoms in emergency department patients with low back pain and radiculopathy (SEBRA)? A double-blind randomised controlled trial. Balakrishnamoorthy R, Horgan I, Perez S, Steele M, Keijzers G. Aug-14 Australia | 58 adult patients with low back pain who had a positive straight leg test and difficulty mobilizing given 8 mg of intravenous dexamethasone (or placebo) in addition to current routine care. | RCT | Visual analogue scores (VAS) at 24 hours | At 24hrs, dexamethasone group had a 1.86 point greater reduction in pain compared to placebo (p=0.02) | Small sample size, no differentiation between acute vs chronic back pain, and baseline VAS score was higher for the treatment arm. There were no differences in functional scores between the two groups. |
| VAS at 6 weeks | Both groups had similar significant and sustained decrease in VAS scores compared with baseline. | ||||
| Straight leg raise angle at discharge | Dexamethasone group improved SLR angle at discharge (p=0.04) | ||||
| Short-term efficacy of intravenous pulse glucocorticoids in acute discogenic sciatica. A randomized controlled trial. Finckh A, Zufferey P, Schurch M, Balagué F, Waldburger M, So A. Feb-06 Switzerland | Patients with acute sciatica of radiologically confirmed discogenic origin were randomized to receive either a single IV bolus of 500 mg of methylprednisolone or placebo. | RCT | Reduction in sciatic leg pain during the first 3 days following the infusion | Glucocorticoids provided significant improvement in sciatic leg pain. However, the effect size was small, and the improvement did not persist | Small sample size, therapeutic efficacy was hindered by regression to the mean, and unblinding might have occurred as a result of transient glucocorticoid side effects. Results of this study can only be generalized to patients with severe acute discogenic sciatica. |
| Functional disability, and signs of radicular irritation | Glucocorticoids had no effect on disability or clinical signs of radicular irritation |
Author Commentary:
Glucocorticoids are used in sciatica with the expectation that their anti-inflammatory effects can reduce the inflammation and swelling associated with nerve root irritation. Additional studies have assessed systemic corticosteroid treatments in back pain, but they used tapered dosing for at least 7 days or included patients without radiculopathy. These two studies provided low-quality evidence of a small short-term benefit in pain relief with intravenous glucocorticoids but no significant benefit in disability or functional outcomes.
Bottom Line:
There is insufficient evidence to support the use of intravenous single-dose glucocorticoids in people with low back pain with radiculopathy (sciatica).
References:
- Balakrishnamoorthy R, Horgan I, Perez S, Steele M, Keijzers G.. Does a single dose of intravenous dexamethasone reduce symptoms in emergency department patients with low back pain and radiculopathy (SEBRA)? A double-blind randomised controlled trial.
- Finckh A, Zufferey P, Schurch M, Balagué F, Waldburger M, So A. . Short-term efficacy of intravenous pulse glucocorticoids in acute discogenic sciatica. A randomized controlled trial.