Oral Steroids Have Little Effect in Patients With Sciatica

Yael Waknine

May 20, 2015

A short course of oral prednisone slightly improves function but has no effect on acute radicular leg pain (sciatica) or subsequent need for surgery among patients with a herniated lumbar disk, according to a study published in the May 19 issue of JAMA.

Although oral steroids are commonly used as a less-invasive alternative to epidural steroid injections for lumbar radiculopathy, their efficacy has not been evaluated in appropriately powered clinical trials, write Harley Goldberg, DO, from the Kaiser Permanente Northern California Spine Care Program, San Jose, California, and colleagues.

Therefore, the team conducted a study of 269 adults with acute radicular pain (onset within 3 months), magnetic resonance imaging evidence of a herniated disk, and an Oswestry Disability Index (ODI) score of 30 or higher.

Participants were randomly assigned to receive a tapering 15-day course of oral prednisone (5 days each of 60, 40, and 20 mg, for a total cumulative dose of 600 mg) or matching placebo. Results were adjusted for baseline demographics, study site, presence of a positive straight-leg raise test result at baseline, and time elapsed between symptom onset and randomization.

Compared with placebo, treatment with prednisone yielded a mean 6.4-point (95% confidence interval [CI], 1.9 - 10.9 points; P = .006) improvement in ODI scores at 3 weeks and a mean 7.4-point (95% CI, 2.2 - 12.5 points; P = .005) benefit at 52 weeks.

However, there was no statistically significant difference between groups with respect to below-waist pain, as rated on a scale of 0 to 10. Patients in the prednisone group reported mean improvements over placebo of 0.3 points (95% CI, −0.4 - 1.0 points; P = .34) and 0.6 points (95% CI, −0.2 - 1.3 points; P = .15) at 3 and 52 weeks, respectively.

With or without treatment, most patients got better: no significant intergroup difference was found in the 1-year risk for undergoing microdiscectomy surgery (9.9% vs 9.1%; relative risk, 1.2; 95% CI, 0.5 - 2.6; P = .68).

Use of steroids was linked to typical adverse events, such as mild insomnia (25.7%), nervousness (18.4%), and increased appetite (22.3%). By week 52, the mean number of adverse events was similar between groups (P = .98). The five serious adverse events reported during the course of 1 year, three of which occurred in prednisone-treated patients, were not deemed to be related to the medication study.

Will Clinicians Change Their Prescribing Habits?

Although most studies have concluded that oral steroids have little effect on lumbar radiculopathy, clinicians have continued to use these drugs. According to Eeric Truumees, MD, this is likely the result of balancing a patient's need for perceptible treatment with the knowledge that the pain will typically improve soon.

"As painful as pinched nerve problems can be, the majority of them improve on their own. However, patients coming to their doctor with significant pain and limited function will strongly encourage that caregiver to do something. The doctor, recognizing that the pain will typically improve soon, does not want to recommend an overly aggressive or risky treatment option. For most patients, a short course of oral steroids is not deemed risky, and the side effects let the patients know something is happening. Given how frequently most patients with sciatica will improve during, or shortly after, the course of steroids ends, it is not surprising that they (and often the physicians too) believe the steroids were effective," Dr Truumees told Medscape Medical News.

Dr Truumees is director of the Spine Trauma Program at Brackenridge University Medical Center and attending spine surgeon at the Seton Medical Center in Austin, Texas. He also serves as editor-in-chief of AAOS Now and is deputy editor of the Spine Journal.

"A number of studies have asked the question, 'Does a short course of oral steroids speed recovery from lumbar radiculopathy?' This larger, well-conducted study more convincingly answers the question with a 'Probably not.' It remains to be seen whether the clinicians will respond by changing their prescribing patterns," Dr Truumees concluded.

The study was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases to Dr Goldberg and one coauthor. One coauthor reports receiving travel support from the US Army, grants from the Orthopaedic Research and Education Foundation and AOSpine, and options from Simpirica and Intrinsic Orthopedics. The other authors and Dr Truumees have disclosed no relevant financial relationships.

JAMA. 2015;313:1924-1938. Abstract

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