• 
• 

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
[(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.

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Balakrishnamoorthy R, et al Aug 2014 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)
Finckh A Feb 2006 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

Comment(s)

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.

Clinical 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

1. 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. Emerg Med J 2015;32(7):525-530.
2. 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. Spine 2006;31(4):377-381