Abstract
To the Editor:
We read with great interest the meta-analysis by Wang et al on the clinical outcomes of annulus fibrosus repair following lumbar discectomy, published in Global Spine Journal in 2023. 1 The authors conducted a comprehensive synthesis of controlled trials and provided valuable insights into the potential role of annulus repair in reducing recurrence and improving patient-reported outcomes. However, upon close examination, we identified a methodological issue that warrants clarification and correction. In the text of their article, Wang et al classified the study by Jiang et al. (2017) as a randomized controlled trial (RCT). 2 Careful review of the original publication, which was written in Chinese, demonstrates that the authors merely stated that patients were “divided into experimental and control groups” without specifying random allocation. The methodological description lacks mention of randomization procedures, allocation concealment, or blinding—hallmarks that distinguish an RCT from a non-randomized controlled study. In fact, the study should be more appropriately classified as a prospective controlled clinical trial rather than an RCT. This misclassification has important implications. RCTs are considered the gold standard in clinical research because they minimize selection bias and confounding, thereby yielding higher-quality evidence. 3 Mislabeling a non-randomized study as an RCT artificially inflates the level of evidence and may lead to erroneous grading of study quality in meta-analyses. Moreover, in Wang et al.’s article, subgroup analyses were performed according to study design (RCTs vs non-RCTs). Including a non-randomized study in the RCT subgroup risks distorting pooled effect estimates and could misinform clinical interpretation, especially when the total number of true RCTs in this field remains limited. Accurate classification of study design is fundamental to the credibility of systematic reviews and meta-analyses. Even a single error can mislead readers, policymakers, and clinicians who rely on such work to inform surgical decision-making. We therefore respectfully recommend that the authors and journal consider issuing a clarification or correction to ensure the integrity of the published evidence base. We hope this clarification will help maintain the rigor and reliability of evidence in this field.
