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Three Part Question

In [symptomatic adult patients with acute lower back pain with radiculopathy], do [single-dose systemic steroids] improve [short-term (< 1 week) symptoms relief] ?

Clinical Scenario

A 40 year-old male patient presents to your emergency department with a five days history of sudden onset low back pain irradiating to the posterior aspect of his left leg. You perform a straight leg raise test, confirming the diagnosis of sciatica without any classic back pain red flags. In addition to standard analgesia, you wonder if a single-dose systemic corticosteroids could help relieve his pain.

Search Strategy

The research was conducted on March 9th, 2015.
A. No BestBETs or critical appraisals were found on this topic.
B. The website clinicaltrials.gov was searched for an ongoing trial on the topic: no trials were found.

C. MEDLINE (PUBMED) : ((((((((((((corticosteroid) OR glucocorticoid) OR hydrocortisone) OR methylprednisolone) OR dexamethasone) OR prednisolone) OR prednisone) OR steroid)) AND (((radicular pain) OR radiculopathy) OR sciatica)) AND controlled trial)) 197 papers
- After abstract/title review = 2 relevant papers.

D. EMBASE :
1) 'corticosteroid'/exp OR corticosteroid OR 'glucocorticoid'/exp OR glucocorticoid OR 'hydrocortisone'/exp OR hydrocortisone OR 'methylprednisolone'/exp OR methylprednisolone OR 'dexamethasone'/exp OR dexamethasone OR 'prednisolone'/exp OR prednisolone OR 'prednisone'/exp OR prednisone OR 'steroid'/exp OR steroid : 1 294 927 papers
2) 'radicular pain' OR radiculopathy OR sciatica : 16 813 papers
3) 'controlled trial' : 452 884 papers
4) 1 AND 2 AND 3 : 249 papers

- After abstract review = 2 relevant papers (including preceding relevant papers).

E. Cochrane : There were no Cochrane review on the subject.

Search Outcome

Relevant papers about adults = 2.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Balakrishnamoorthy et al. 2014 Australia	58 patients (18-55 yo) presenting to two ED with low back pain and positive SLR. Randomized to dexametha-sone 8mg IV single-dose or placebo.	Double-blind RCT (2b)	Change on 10 cm VAS pain score at discharge	No significant difference (-3.00 in SCS vs -2.32 placebo, p = 0.42)	Small population. 83 patients not recruited despite eligibility and 10 patients lost to follow-up. Missing information on coanalgesia used besides opiates. Initial pain scores were more severe in SCS group. Patients self evaluated their pain at 24h without precision on the position they had to be in.
			Change on 10 cm VAS pain score at 24h	-2.63 in SCS vs -0.77 in placebo, p = 0.019
			ED length of stay (median)	Shorter LOS in SCS group 3.5 h vs 18.8 h (p = 0.049)
Finckh et al. 2006 Switzerland	65 patients, multicenter, (> 16 yo) hospitalized with acute sciatica (> 1 week and <6 weeks) of confirmed discogenic etiology. Randomized to methylpredni-solone 500 mg IV single-dose or placebo. Both group received “standard analgesics”.	Double-blind RCT (2b)	Difference on 10 cm VAS leg pain score improvement at 24h	0,57 cm difference in favour of SCS (95% CI 0.3– 10.9 )	Small population. Clinical significance of 0,57 cm difference in pain reduction is unclear. Population of patients hospitalized for severe discogenic sciatica might limit generalizability of results to ED population.
			Difference on 10 cm VAS leg pain score improvement at 72h	No significant difference

Comment(s)

Only two papers have studied the immediate effect of a single systemic IV glucocorticoid pulse to treat sciatica pain. The results of both studies show a small and transient benefit in pain reduction at 24h associated with a possible reduction in median ED length of stay that could prove to be clinically significant in today's overcrowded emergency rooms. Even though the difference in pain reduction lost statistical significance at follow up in both studies with persistent but comparable pain reduction in both groups, ED oriented outcomes such as acute pain control showed promise. In addition, only minor adverse events were found (1 anal itching, 2 transient hyperglycemia, 1 facial flushing) despite very high doses in one of the papers. Other studies measuring long-term pain reduction with systemic steroids were excluded for this research, including two meta-analysis showing non-significant effects beyond 1 week of single and tapering glucocorticoid doses. Notable exclusion criteria for both studies were prior lumbar surgery and concomitant steroid therapy.

Clinical Bottom Line

In symptomatic adult patients with acute lower back pain with radiculopathy, a single-dose IV steroid pulse could result in short-term pain reduction and shorten patients ED length of stay. However, larger RCT are needed to confirm the results shown in previous studies.

References

1. Balakrishnamoorthy, R. Horgan, I. Perez, S. Steele, MC. 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. Emergency Medicine Journal 2014 Aug 13; 0:1–6. doi:10.1136/emermed-2013-203490
2. Finckh, A. Zufferey, P. Schurch, MA. Balagué, F. Waldburger, M. So, A. Short-Term Efficacy of Intravenous Pulse Glucocorticoids in Acute Discogenic Sciatica. A Randomized Controlled Trial. Spine 2006; Volume 31, Number 4, pp 377–381.