Results are mixed for treating disk pain with steroids

DEAR DOCTOR K: I have terrible sciatica pain from a slipped disk, but I've hesitated to take steroid pills. What do you think about this treatment?

DEAR READER: Your spine is essentially a column of interlocking bones called vertebrae. A disk tucked in between each pair of vertebrae acts as a shock-absorbing cushion. Sciatica often occurs when a disk becomes displaced (herniated) in the lower spine and injures or compresses the sciatic nerve. This causes sciatica, a severe, shooting pain, tingling, numbness or weakness that runs from your lower back through the buttock and into the lower leg. (On my website, AskDoctorK.com, I've put an illustration showing common causes of sciatica.)

Doctors often prescribe steroids to relieve the sudden, severe pain of disk-related nerve compression, and some back-pain guidelines include them as an appropriate treatment. But steroid pills have not been well studied for treating sciatica.

A study recently published in the Journal of the American Medical Association helps to evaluate the effectiveness of this treatment. The study looked at 269 adults with sciatic nerve pain caused by a herniated disk. They were randomly assigned to receive two weeks of steroid pills or a placebo. The researchers measured pain and function after they finished treatment and again a year later. The results were mixed:

- Pain was similar in both the steroid and placebo groups.

- Physical function was slightly better in the steroid group.

- The number of people who ended up needing surgery was similar in both groups.

If steroid pills have worked for a particular patient in the past, I would probably recommend them again. However, given the results of this study, I'm likely to encourage most patients to consider other treatments first. For example:

- Rest, balanced with limited activity. (Prolonged bed rest can make matters worse.)

- Gentle exercise, to help you move better and begin to strengthen back muscles. A physical therapist can help design a personalized exercise program.

- Hot or cold compresses.

- Pain medicines such as acetaminophen (Tylenol) and ibuprofen (Motrin, Advil).

- Medicines for nerve pain, such as amitriptyline (Elavil) or gabapentin (Neurontin).

- Chiropractic care, acupuncture or massage.

- Injections of steroids plus an anesthetic.

Surgery may be a reasonable option if a herniated disk is the clear cause of sciatica, and non-surgical treatments just don't give relief from the pain.

It may seem odd for me to talk about a study that showed virtually no benefit from a treatment, and then to say I might prescribe the treatment anyway for certain patients. That's because all a well-done study like this one can do is evaluate whether a particular treatment helps the average patient.

But not all patients with a particular disease are the same. Diseases are not that simple and homogeneous. Some people will respond to a particular treatment; some won't. So if a patient has responded well to a particular treatment in the past, I'll consider prescribing that treatment again. After all, I'm treating a patient, not a study.

Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com, or write: Ask Doctor K, 10 Shattuck St., Second Floor, Boston, MA 02115.