Management of Back Pain

Evidence on Systemic Corticosteroids

Systemic corticosteroids, including dexamethasone, are not recommended for treating back pain with or without sciatica, as they have not been shown to be more effective than placebo for pain relief, according to the American College of Physicians 1, 2
Multiple trials have consistently found no differences between systemic corticosteroids and placebo in pain or function for acute non-radicular low back pain, with a strength of evidence rated as high 1
Six trials consistently found no differences between systemic corticosteroids and placebo in pain relief for radicular low back pain, with a strength of evidence rated as moderate 1
The American College of Physicians recommends against the use of systemic corticosteroids for chronic low back pain, due to a lack of evidence supporting their effectiveness 1

Oral prednisone increases the risk for any adverse event, including insomnia, nervousness, and increased appetite, with a number needed to harm of 4, according to the American College of Physicians 1
Intramuscular dexamethasone is associated with an increased risk for adverse effects, with a relative risk of 6.4, according to the American College of Physicians 1

High-dose dexamethasone should be given immediately when clinical-radiological diagnosis of spinal cord compression is obtained, as recommended by the European Society for Medical Oncology 3
Doses typically range from moderate (16 mg/day) to high (36-96 mg/day), sometimes preceded by an intravenous bolus, according to the European Society for Medical Oncology 3

NSAIDs and skeletal muscle relaxants have shown evidence of effectiveness for acute low back pain, with a strength of evidence rated as high, according to the American College of Physicians 1, 5
NSAIDs, duloxetine, and tramadol have shown moderate evidence of effectiveness for chronic low back pain, with a strength of evidence rated as moderate, according to the American College of Physicians 1, 5
Non-pharmacologic options with proven benefits include spinal manipulation for acute low back pain, and exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation for chronic or subacute low back pain, according to the American College of Physicians 2

Epidural steroid injections may be considered for specific cases of radicular pain, as recommended by the British Medical Journal 6
Some evidence suggests that epidural dexamethasone (4-8 mg) may be effective for lumbar radiculopathy, particularly for disc herniation rather than stenotic lesions, with a strength of evidence rated as low 6