Authors: Goldberg H et al. JAMA 2015 May 19.
And treatment offered no relief from pain.
Oral steroids are used commonly in patients with acute lumbar radiculopathy or sciatica, but strong evidence of benefit is lacking. In this study, researchers at a large California health system randomized 269 patients (mean age, 46) with acute sciatica, magnetic resonance imaging–confirmed disc herniation, and substantial functional impairment to a tapering course of oral prednisone (60 mg daily for 5 days, 40 mg daily for 5 days, and 20 mg daily for 5 days) or placebo. Patients with pain for >3 months, recent epidural or oral steroid use, or previous lumbar surgery were excluded. The 1-year rate of spine surgery was the same in both groups (about 10%).
In adjusted analyses, improvement in function was significantly greater in the prednisone group than in the placebo group (mean difference between groups on a 100-point scale, 6.4 points at 3 weeks and 7.4 points at 52 weeks). A significantly higher proportion of prednisone versus control patients had >50% improvement in function at 3 weeks (33% vs. 20%) and 52 weeks (87% vs. 68%); the corresponding numbers needed to treat to benefit one patient at those time points were 7.6 and 5.5, respectively. No differences were found between groups on any pain measure. Minor adverse effects (e.g., nervousness, insomnia, increased appetite) were roughly twice as common in the prednisone group at 3 weeks.
Mean improvement in function with prednisone was statistically significant, but its clinical importance is marginal (a between-group difference of 5–15 points is suggested as the minimum clinically important difference). However, steroid recipients were more likely than placebo recipients (by about 15 percentage points) to have clinically meaningful >50% improvement in disability scores. This suggests that there might be a subgroup of patients (as yet undefined) who benefit from prednisone. Based on these results, a clinician could tell the patient, “You have a roughly 1 in 7 chance of benefiting from prednisone,” and then allow the patient to decide whether this relatively low probability of benefit is worth pursuing, given the side effects of 15 days of relatively high-dose prednisone and no reduction in eventual need for surgery.