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. 2022 Oct 21;10(10):CD012450.
doi: 10.1002/14651858.CD012450.pub2.

Systemic corticosteroids for radicular and non-radicular low back pain

Roger Chou  1 , Rafael Zambelli Pinto  2 , Rongwei Fu  3   4 , Robert A Lowe  1   4   5 , Nicholas Henschke  6 , James H McAuley  7 , Tracy Dana  8
Affiliations

Systemic corticosteroids for radicular and non-radicular low back pain

Roger Chou et al. Cochrane Database Syst Rev. .

Abstract

Background: Corticosteroids are medications with anti-inflammatory and immunosuppressant properties. Systemic corticosteroids administered through the oral, intravenous, or intramuscular routes have been used to treat various types of low back pain, including radicular back pain (not due to spinal stenosis), non-radicular back pain, and spinal stenosis. However, there is uncertainty about the benefits and harms of systemic corticosteroids for low back pain.

Objectives: To evaluate the benefits and harms of systemic corticosteroids versus placebo or no corticosteroid for radicular low back pain, non-radicular low back pain, and symptomatic spinal stenosis in adults.

Search methods: We used standard, extensive Cochrane search methods. The latest search date was September 2021.

Selection criteria: We included randomized and quasi-randomized trials in adults of systematic corticosteroids versus placebo or no corticosteroid.

Data collection and analysis: We used standard Cochrane methods. The major outcomes were pain, function, need for surgery, serious adverse effect, and presence of hyperglycemia. The minor outcomes were quality of life, successful outcomes, non-serious adverse events, and withdrawal due to adverse events. We used GRADE to assess the certainty of evidence for each outcome.

Main results: Thirteen trials (1047 participants) met the inclusion criteria. Nine trials included participants with radicular low back pain, two trial with low back pain, and two trials with spinal stenosis. All trials blinded participants to receipt of systemic corticosteroids. Seven trials were at low risk of bias, five at unclear risk, and one at high risk of selection bias. Two trials were at high risk of attrition bias. Doses and duration of systemic corticosteroid therapy varied. Radicular low back pain For radicular low back pain, moderate-certainty evidence indicated that systemic corticosteroids probably slightly decrease pain versus placebo at short-term follow-up (mean difference (MD) 0.56 points better, 95% confidence interval (CI) 1.08 to 0.04 on a 0 to 10 scale) and may slightly increase the likelihood of experiencing improvement in pain at short-term follow-up (risk ratio (RR) 1.21, 95% CI 0.88 to 1.66; absolute effect 5% better (95% CI 5% worse to 15% better). Systemic corticosteroids may not improve function at short-term follow-up (standardized mean difference (SMD) 0.14 better; range 0.49 better to 0.21 worse) and probably increase the likelihood of improvement in function at short-term follow-up (RR 1.52, 95% CI 1.22 to 1.91; absolute effect 19% better, 95% CI 8% better to 30% better). Systemic corticosteroids were associated with greater improvement in function versus placebo at long-term follow-up (MD -7.40, 95% CI -12.55 to -2.25 on the 0 to 100 Oswestry Disability Index) and greater likelihood of functional improvement (RR 1.29, 95% CI 1.06 to 1.56), based on a single trial. There was no difference in likelihood of surgery (RR 1.00, 95% CI 0.68 to 1.47). Evidence indicated that systemic corticosteroids (administered as a single dose or as a short course of therapy) are not associated with increased risk of any adverse event, serious adverse events, withdrawal due to adverse events, or hyperglycemia, but estimates were imprecise as some trials did not report harms, and harms reporting was suboptimal in trials that did provide data. Limitations included variability across trials in interventions (e.g. corticosteroid used, dose and duration of treatment), clinical settings, and participants (e.g. duration of symptoms, methods for diagnosis); limited utility of subgroup analyses due to small numbers of trials; methodologic limitations or suboptimal reporting of methods by some trials; and too few trials to formally assess for publication bias using graphical or statistical tests for small sample effects. Non-radicular low back pain Evidence on systemic corticosteroids versus placebo for non-radicular pain was limited and suggested that systemic corticosteroids may be associated with slightly worse short-term pain but slightly better function. Spinal stenosis For spinal stenosis, limited evidence indicated that systemic corticosteroids are probably no more effective than placebo for short-term pain or function.

Authors' conclusions: Systemic corticosteroids appear to be slightly effective at improving short-term pain and function in people with radicular low back pain not due to spinal stenosis, and might slightly improve long-term function. The effects of systemic corticosteroids in people with non-radicular low back pain are unclear and systemic corticosteroids are probably ineffective for spinal stenosis. A single dose or short course of systemic corticosteroids for low back pain does not appear to cause serious harms, but evidence is limited.

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Conflict of interest statement

RC has conducted systematic reviews funded by the Agency for Healthcare Research and Quality and the American Pain Society that included systemic corticosteroids, and he led a guideline from the American College of Physicians and the American Pain Society that addressed systemic corticosteroids.

RZP: none.

RF: Oregon Health & Science University (employment).

RL owns stocks in companies that make systemic corticosteroids (Pfizer Inc, Amgen, Eli Lilly and Company, Merck, Johnson & Johnson Health Care Systems Inc, Gilead Sciences). His declaration was referred to the Cochrane Funding Arbiter, and it was determined that there was no breach of Cochrane policy.

NH: none.

JHM: none

TD: none.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgments about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgments about each risk of bias item presented as percentages across all included studies.
4
4
Corticosteroid versus placebo, immediate‐term (less than two weeks) pain (continuous).
5
5
Corticosteroid versus placebo, short‐term (two weeks to three months) pain (continuous).
6
6
Corticosteroid versus placebo, immediate‐term (less than two weeks) pain (dichotomous).
7
7
Corticosteroid versus placebo, short‐term (two weeks to three months) pain (dichotomous).
8
8
Corticosteroid versus placebo, intermediate‐term (greater than three to less than 12 months) pain (dichotomous).
9
9
Corticosteroid versus placebo, long‐term (12 months or greater) pain (dichotomous).
10
10
Corticosteroid versus placebo, immediate‐term (less than two weeks) function (continuous).
11
11
Corticosteroid versus placebo, short‐term (two weeks to three months) function (continuous).
12
12
Corticosteroid versus placebo, immediate‐term (less than two weeks) function (dichotomous).
13
13
Corticosteroid versus placebo, short‐term (two weeks to three months) function (dichotomous).
14
14
Corticosteroid versus placebo, long‐term (12 months or greater) function (dichotomous).
15
15
Corticosteroid versus placebo, subsequent surgery.
16
16
Corticosteroid versus placebo, hyperglycemia.
17
17
Corticosteroid versus placebo, immediate‐term (less than two weeks) global improvement.
18
18
Corticosteroid versus placebo, any adverse event.
19
19
Corticosteroid versus placebo, withdrawal due to adverse events.
1.1
1.1. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 1: Pain (dichotomous), immediate (< 2 weeks) – by type of pain
1.2
1.2. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 2: Pain (dichotomous), short‐term (2 weeks to 3 months) – by type of pain
1.3
1.3. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 3: Pain (dichotomous), intermediate (> 3 to < 12 months)
1.4
1.4. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 4: Pain (dichotomous), long‐term (≥ 12 months)
1.5
1.5. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 5: Function (dichotomous), immediate (< 2 weeks) – by type of pain
1.6
1.6. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 6: Function (dichotomous), short‐term (2 weeks to 3 months) – by type of pain
1.7
1.7. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 7: Function (dichotomous), short‐term (radicular) – by corticosteroid dose
1.8
1.8. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 8: Function (dichotomous), short‐term (radicular) – by dosing regimen
1.9
1.9. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 9: Function (dichotomous), short‐term (radicular) – by route of administration
1.10
1.10. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 10: Function (dichotomous), short‐term (radicular) – by clinical setting
1.11
1.11. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 11: Function (dichotomous), short‐term (radicular) – by duration of symptoms
1.12
1.12. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 12: Function (dichotomous), short‐term (radicular) – by imaging correlation
1.13
1.13. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 13: Function (dichotomous), short‐term (radicular) – by risk of bias
1.14
1.14. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 14: Function (dichotomous), long‐term (≥12 months)
1.15
1.15. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 15: Surgery (radicular)
1.16
1.16. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 16: Surgery (radicular) – by risk of bias
1.17
1.17. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 17: Surgery (radicular) – by route of administration
1.18
1.18. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 18: Surgery (radicular) – by duration of symptoms
1.19
1.19. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 19: Surgery (radicular) – by imaging correlation
1.20
1.20. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 20: Serious adverse events
1.21
1.21. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 21: Hyperglycemia – by route of administration
1.22
1.22. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 22: Hyperglycemia – by type of pain
1.23
1.23. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 23: Hyperglycemia – by clinical setting
1.24
1.24. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 24: Hyperglycemia – by imaging correlation
1.25
1.25. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 25: Global improvement, immediate (< 2 weeks)
1.26
1.26. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 26: Global improvement, immediate (radicular) – by route of administration
1.27
1.27. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 27: Any adverse event – by duration of symptoms
1.28
1.28. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 28: Any adverse event – by type of pain
1.29
1.29. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 29: Any adverse event – by clinical setting
1.30
1.30. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 30: Any adverse event – by risk of bias
1.31
1.31. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 31: Any adverse event – by corticosteroid dose
1.32
1.32. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 32: Any adverse event – by imaging correlation
1.33
1.33. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 33: Any adverse event – by dosing regimen
1.34
1.34. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 34: Any adverse event – by route of administration
1.35
1.35. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 35: Gastrointestinal adverse events – by duration of symptoms
1.36
1.36. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 36: Gastrointestinal adverse events – by type of pain
1.37
1.37. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 37: Gastrointestinal adverse events – by clinical setting
1.38
1.38. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 38: Gastrointestinal adverse events – by corticosteroid dose
1.39
1.39. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 39: Gastrointestinal adverse events – by imaging correlation
1.40
1.40. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 40: Gastrointestinal adverse events – by dosing regimen
1.41
1.41. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 41: Gastrointestinal adverse events – by route of administration
1.42
1.42. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 42: Withdrawal due to adverse events
1.43
1.43. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 43: Withdrawal due to adverse events (radicular) – by duration of symptoms
1.44
1.44. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 44: Withdrawal due to adverse events (radicular) – by route of administration
1.45
1.45. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 45: Withdrawal due to adverse events (radicular) – by clinical setting
1.46
1.46. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 46: Withdrawal due to adverse events (radicular) – by dosing regimen
1.47
1.47. Analysis
Comparison 1: Corticosteroid versus placebo, Outcome 47: Withdrawal due to adverse events (radicular) – by imaging correlation
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Comment in

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Chou 2016
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