Summary of findings 1. Systemic corticosteroids compared with placebo for radicular low back pain (not due to spinal stenosis).
| Systemic corticosteroids compared with placebo for radicular low back pain (not due to spinal stenosis) | ||||||
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Patient or population: people with radicular low back pain (not due to spinal stenosis) Settings: primary care, emergency room, or inpatient Intervention: systemic corticosteroid Comparison: placebo | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect (95% CI) | No of participants (trials) | Certainty of the evidence (GRADE) | Comments | |
| Assumed risk | Corresponding risk | |||||
| Placebo or no systemic corticosteroid | Systemic corticosteroid | |||||
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Pain (continuous) Standardized to 0–10 scale Follow‐up: short‐term (2 weeks to < 3 months) |
The mean pain score in the placebo groups ranged from 2.0 to 4.32a | The mean pain score in the intervention groups was 0.56 points better (1.08 better to 0.04 better) | Not applicable | 430 (5) | ⊕⊕⊕⊝ Moderateb | Systemic corticosteroids probably slightly decrease pain at short‐term follow‐up. |
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Pain (dichotomous) Pain improved (definitions varied)c Follow‐up: short‐term (2 weeks to < 3 months) |
302/1000 | 365/1000 (266 to 501) | RR 1.21 (0.88 to 1.66) | 345 (2) | ⊕⊕⊕⊝ Moderated | Systemic corticosteroids may slightly increase the likelihood of experiencing improvement in pain at short‐term follow‐up. Absolute effect 5% better (5% worse to 15% better); relative effect 21% better (12% worse to 66% better). |
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Function (continuous) SMD (scales varied) Follow‐up: short‐term (2 weeks to < 3 months) |
In the placebo groups, the mean score on the ODI (scale 0 to 100) ranged from 20.7 to 41.1 (3 trials) and the mean score on the RDQ was 4.1 (1 trial) | The SMD for function in the intervention groups was 0.14 better (range 0.49 better to 0.21 worse); the MD ranged from 2.90 better to 6.40 better on the ODI (3 trials) and 2.70 points worse on the RDQ (1 trial) | Not applicable | 364 (4) | ⊕⊕⊝⊝ Lowd,e | Systemic corticosteroids may not improve function at short‐term follow‐up. |
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Function (dichotomous) Function improved (definitions varied)f Follow‐up: short‐term (2 weeks to < 3 months) |
342/1000 | 520/1000 (417 to 653) | RR 1.52 (1.22 to 1.91) | 403 (3) | ⊕⊕⊕⊝ Moderateg | Systemic corticosteroids probably increase the likelihood of experiencing improvement in function at short‐term follow‐up. Absolute effect 19% better (8% better to 30% better); relative effect 52% better (22% better to 91% better). |
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Participants who underwent surgery Underwent surgery Follow‐up: varied (within 30 days, within 90 days, within 6 months, within 52 weeks, or within an unspecified time frame) |
171/1000 | 171/1000 (116 to 251) | RR 1.00 (0.68 to 1.47) | 442 (5) | ⊕⊕⊕⊝ Moderated | Systemic corticosteroids probably have no effect on the likelihood of subsequent surgery. |
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Participants who experienced a serious adverse event Adverse event requiring hospitalization or resulting in death Follow‐up: long‐term (≥ 12 months) |
23/1000 | 17/1000 (3 to 100) | RR 0.74 (0.13 to 4.33) | 267 (2) | ⊕⊝⊝⊝ Very lowd,h,i,j | We are uncertain whether systemic corticosteroids have an effect on the likelihood of experiencing serious adverse events. |
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Participants with hyperglycemia "Transient hyperglycemia" or blood sugar increase ≥ 50 mg/dL Follow‐up: immediate‐term (< 2 months), based on duration of treatment |
232/1000 | 248/1000 (109 to 573) | RR 1.07 (0.47 to 2.47) | 151 (2) | ⊕⊕⊝⊝ Lowd,k | Systemic corticosteroids (administered as a single large dose or as a short course) may not increase the likelihood of experiencing hyperglycemia. Absolute effect 5% worse (14% worse to 4% better); relative effect 7% worse (53% better to 147% worse). |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; LBP: low back pain; MD: mean difference; ODI: Oswestry Disability Index; RDQ: Roland Morris Disability Questionnaire; RR: risk ratio; SMD: standardized mean difference. | ||||||
| GRADE Working Group grades of evidence High certainty: further research is very unlikely to change our confidence in the estimate of effect. Moderate certainty: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low certainty: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low certainty: we are very uncertain about the estimate. | ||||||
aBased on the mean pain score reported at follow‐up in the placebo groups in the trials. bDowngraded one level for risk of bias (three of five trials were at high risk of bias). cDefinitions were no back pain in previous 24 hours (Friedman 2008), or improvement in pain score of 5 points or greater on a 0 to 10 scale (Goldberg 2015). dDowngraded one level due to imprecision (confidence interval for pooled estimate crossed zero for continuous outcomes or crossed one for dichotomous outcomes). eDowngraded one level for risk of bias (three of four trials were at high risk of bias). fDefinitions were able to resume normal activity (Balakrishnamoorthy 2015), RDQ‐18 = 0 (Friedman 2008), or improvement in pain score of 5 points or greater on a 0 to 10 scale (Goldberg 2015). gDowngraded one level due to indirectness (variability in definitions of functional improvement). hDowngraded one level due to risk of bias (all trials had unclear risk of bias). iDowngraded one level for inconsistency (I² = 43%). jDowngraded one level for indirectness (poorly defined and variable definitions). kDowngraded one level due to risk of bias (one trial had unclear risk of bias and the other trial had high risk of bias).