Abstract
Dear Editor,
We read with great interest the study by Li et al evaluating spinal stability after more than 50% resection of the inferior articular process (IAP) during single-segment unilateral interlaminar endoscopic lumbar discectomy (IELD). 1 The authors reported that, among 51 patients with more than 50% IAP resection, no radiographic segmental instability was observed during follow-up, and IAP bone regeneration was detected in some patients, whereas no regeneration was observed after complete IAP resection. These findings are clinically meaningful. Nevertheless, several points may merit further consideration to enhance the interpretation and clinical applicability of this work.
First, the important finding that no segmental instability was observed could be further strengthened by being interpreted together with an estimate of the risk interval. The absence of radiographic segmental instability in this cohort is clinically reassuring. However, for a zero-event outcome, reporting only that no instability was observed may not fully convey the statistical uncertainty surrounding the true risk. Future studies could consider reporting an exact 95% confidence interval or an estimated upper boundary of risk to help distinguish “no instability observed in this cohort” from “a low but not necessarily absent underlying risk.” Such statistical framing would not weaken the conclusion; rather, it would enhance the robustness and clinical interpretability of the findings.
Second, the extent of IAP resection may warrant further evaluation beyond a binary classification and toward a dose–response framework. Although more than 50% IAP resection was used as the inclusion threshold, the actual extent of resection varied widely, and different patterns of bone regeneration were observed between partial and complete resection. Therefore, analyzing IAP resection rate as a continuous variable, or exploring potential clinical thresholds such as 70%, 80%, 90%, and complete resection, may help address a key surgical question: at what degree of IAP resection should greater caution be exercised while adequate decompression is maintained? Such analyses would help translate the overall conclusion that resection beyond 50% does not necessarily lead to instability into more actionable intraoperative decision-making guidance.
Third, these findings have important implications for postoperative management and follow-up stratification. Although supplemental fixation and fusion may not always be required after more than 50% of the IAP is resected to achieve adequate decompression during IELD, patients with different extents of resection may require different postoperative management strategies. Future studies could perform subgroup or interaction analyses according to age, surgical level, preoperative degeneration, postoperative disc height loss, and IAP regeneration status. Such analyses may help identify patients who would benefit from closer early ODI or pain assessment, flexion–extension radiographic surveillance, brace guidance, and structured back-muscle rehabilitation.
Overall, the study by Li et al provides valuable real-world evidence regarding segmental stability after extensive IAP resection during IELD. The clinical translational value of these findings would be further enhanced if future research incorporated risk-interval estimation, dose–response assessment, and stratified follow-up pathways.
