Oral Steroids Ineffective Against Back Pain

  • Posted by a hidden member.
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    May 27, 2015 2:19 AM GMT
    NYT: Prednisone is almost completely ineffective as a treatment for the pain caused by a herniated disk, a randomized trial has found.

    http://well.blogs.nytimes.com/2015/05/25/oral-steroids-may-be-ineffective-against-sciatica-back-pain/?ref=health
  • LJay

    Posts: 11612

    May 28, 2015 12:25 AM GMT
    I thought that prednisone was primarily an anti-inflammatory drug. Wouldn't a herniated disc be more about pressure on the nerve than inflammation, though swelling could be present. Perhaps it is prescribed because strong pain relievers would put the patient out of most activity and the prednisone gives at least some relief? Doctors, can you comment?
  • NursePractiti...

    Posts: 232

    May 28, 2015 12:59 PM GMT
    According to the guidelines, (2012) epidural injected steroids are recommended for short term relief, and of course some surgical options. Surgical options are not always the best and outcomes vary. Diclofenac and gabapentin are rated as grade 1 recommendations meaning insufficient evidence for or against treatment. Some of my patients do find relief with this. Oral steroids, NSAID's, etc are also used but not enough studies per a note in the guidelines have been done to assess true effectiveness. As for opioid's, they are not recommended as a first line treatment because of the side effects or actual improvement of symptoms when compared with NSAID's or Tylenol.

    https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf
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    May 29, 2015 2:02 AM GMT

    I had never heard of taking this steroid, (Prednisolone) for sciatica until a coworker told me about "a pill" you take, this was back in 2007 when I first had symptoms and before I had a MRI done to confirm my disk degenerative @ L2-3, L5.

    I wont say that the 21 pills of Prednisolone I took were "ineffective" as this article claims, there are not enough people for this study to conclude. I do remember the steroid activating my acne, horribly. The treatment did work for me, at least temporary. In the same 2007 year, after my MRI, I was sent to physical therapy which is where I truly learned how to control my sciatic with proper exercise and yoga. Electric stimulus, cold pack and massage got immediate relief with a few days treatment.

    Today, I still use exercise as a way to control any onset of lower back pain but I know this method is not for everyone who suffers from this pain, especially people who do not exercise on a regular basis or those that are obese. Over the long term, I would not recommend using steroid for back pain, only for immediate need or relief.
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    May 29, 2015 6:21 AM GMT
    Sigh.

    One study, among many..
  • ryno

    Posts: 105

    May 29, 2015 3:09 PM GMT
    LJay saidI thought that prednisone was primarily an anti-inflammatory drug. Wouldn't a herniated disc be more about pressure on the nerve than inflammation, though swelling could be present. Perhaps it is prescribed because strong pain relievers would put the patient out of most activity and the prednisone gives at least some relief? Doctors, can you comment?



    Exactly. If it's a symptomatic disc it wont improve with simply popping a pill. It has to be mechanically reduced (ie exercise/movement) in the correct direction for relief and management (or attempted anyway).
    It would be like having your finger painfully jammed in a door then downing some Aleve to stop the pain. How about getting your finger out of the door?

    Although keep in mind:
    -Not all disc bulges are symptomatic.
    -Not all disc bulges will cause neurologic symptoms.
    -It's actually quite useless to give back pain a specific tissue diagnosis unless severe spine pathology (only 2% or less of all back pain cases).
  • Posted by a hidden member.
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    May 29, 2015 6:12 PM GMT
    ryno said
    Exactly. If it's a symptomatic disc it wont improve with simply popping a pill. It has to be mechanically reduced (ie exercise/movement) in the correct direction for relief and management (or attempted anyway).
    It would be like having your finger painfully jammed in a door then downing some Aleve to stop the pain. How about getting your finger out of the door?

    Although keep in mind:
    -Not all disc bulges are symptomatic.
    -Not all disc bulges will cause neurologic symptoms.
    -It's actually quite useless to give back pain a specific tissue diagnosis unless severe spine pathology (only 2% or less of all back pain cases).


    The door analogy isn't necessarily the best for most causes of herniated discs since the inciting incident is not ongoing.

    With herniation, there is a significant amount of inflammation (the gel-like inner portion of the disc is noxious to nerve roots), and there are many people who find relief with oral steroids for acute disc herniations. Anecdotally, I can recall at least a dozen of my patients in the past two years who had significant relief with a Medrol dose pack.

    Additionally, with a study size of 267, it's not surprising that there were no statistically significant differences between the steroid and placebo arms; moreover, they don't mention in the article to dose of prednisone -- and in my practice Medrol (methyprednisolone) is much more common -- so it's tough to really use this one study to guide/change clinical practice. Plenty of people get relief from steroids for back pain.
  • ryno

    Posts: 105

    Jul 02, 2015 4:25 AM GMT
    [quote][cite]afazia said[/cite]
    ryno said

    ...for most causes of herniated discs since the inciting incident is not ongoing.

    quote]

    Yes, it is. Back and even neck pain is chronic-recurring in nature. If you get back pain once you're more than likely to get it again. A herniated disc is part of a continuum, on one end a simple back ache (mild disc bulge) to the other end of sequestration.
    Yes you can dope up a patient on anti-inflammatories/pain killers, and yes this might alleviate their symptoms in the meantime. But is this considered a success or a "cure?" Hell no. Check back with them in 6-12 months, it's doubtful that they'll be doing just fine - in fact, the literature shows that long term outcomes are quite poor.

    Treatment needs to be for long term management - corrective exercise and postural modification. It sounds way too simple, but it is the overwhelmingly most effective treatment. And yes we can talk about surgery being effective for some cases and meds being good for acute pain, etc, etc, but we're talking about the broader picture here.