Dr. Roach: Can sciatica be relieved through steroid shots?

Dear Dr. Roach: I am wondering what the best treatment is for sciatic pain. Would a steroid shot help? The pain is behind my knee, down the outside of my leg and now on my foot.

— J.F.

Dear J.F.: “Sciatica” is a general term for a process that compresses the nerve roots, causing symptoms such as pain, numbness, tingling and loss of reflexes. The sciatic nerve supplies much of the innervation to the leg. The area you describe is most likely the first sacral nerve (S1), and pain here is most frequently caused by disc herniation at the L5-S1 space. This can cause acute symptoms that are often quite severe.

Initial treatment is usually conservative, consisting of anti-inflammatories and avoiding activities that worsen pain. While bed rest was sometimes prescribed, it is seldom necessary for more than a day or two, and many people actually feel better when they are up and about. After a week, most people are able to do light activity, and I tell my patients neither to push themselves to do more than they can, nor to force themselves to rest if they feel OK with light activity.

Steroids have certainly been used in this situation, and they are injected into the epidural space by an expert who uses imaging. Although there is a slight improvement in pain at three months among those treated with epidural steroids, there was no longer a benefit found at six months. This means that you get better only a little faster than normal at the cost of a small risk from the injection.

If a person isn’t recovering well within a few weeks, I often refer them to physical therapy. If they aren’t getting benefit at all (or they are getting worse), then it is time to find out what the cause is with an MRI and a referral to an expert.

Dear Dr. Roach: I recently read some comments stating there are studies that indicate taking metoprolol can cause Raynaud’s. I have been taking 25 mg of metoprolol daily (to control palpitations, not for high blood pressure) for about eight years, and last year, I was diagnosed with Raynaud’s. Are these comments accurate? I do not have any known autoimmune diseases that would indicate secondary Raynaud’s.

— H.B.

Dear H.B.: Raynaud’s phenomenon (RP) is an accentuated physiological response to cold. When the known diseases that cause RP aren’t found, we call it primary RP.

Drugs that constrict blood vessels can certainly precipitate RP. Decongestants, amphetamines, some cancer chemotherapy drugs and cocaine are more likely on the list than beta blockers like metoprolol. But what you read is correct. Metoprolol, even at the low dose you take, can sometimes cause RP. However, it’s also possible that you just have primary RP, and metoprolol has nothing to do with it.

It’s worth rethinking whether you need metoprolol. Palpitations can happen in healthy people without any pathological heart issues. If you have a known reason for the palpitations, ask your cardiologist (or whomever is prescribing the metoprolol) whether it would be possible for you to take a calcium blocker. Some calcium-channel blockers are vasodilators and are the first-line treatment for primary RP.

Unfortunately, the calcium blockers with antiarrythmic properties are not effective with RP, so it’s possible that you may need both.

Readers may email questions to ToYourGoodHealth@med.cornell.edu.