We agree that our retrospective design represents level III evidence and that multivariable analysis could further elucidate predictors of surgical conversion. Our primary objective, however, was exploratory—to determine whether intradiscal steroid injection (ISI) could provide meaningful short-term pain relief and delay the need for surgery in patients with lumbar spinal stenosis. Because the study population was relatively homogeneous, univariable comparisons were considered appropriate for this initial investigation. Nevertheless, we fully acknowledge that prospective, controlled studies with multivariable modeling are needed to validate and refine these findings.

We appreciate the comments regarding patient positioning and injectate compatibility. The lateral decubitus position used in our study is consistent with the conventional approach applied in diagnostic discography. Based on our experience, this position allows patients to breathe more comfortably than the prone position, thereby enhancing procedural tolerance. Moreover, before needle insertion, the C-arm was adjusted to obtain true anteroposterior and lateral views, and the patient’s body was secured with tape to minimize motion, ensuring stable imaging throughout the procedure. Therefore, we believe that the lateral decubitus approach does not compromise fluoroscopic accuracy compared with the prone position.

Regarding the mixture of dexamethasone and ropivacaine, we are aware that this combination may exhibit limited physicochemical compatibility under certain conditions. However, it is important to note that their letter primarily raised a theoretical concern rather than reporting any clinical adverse events. In fact, numerous clinical studies involving nerve blocks, intra-articular injections, and intradiscal procedures have used this combination safely without evidence of precipitation or clinically significant reactions. In our own cohort of 260 patients, the mixture was freshly prepared and immediately administered under fluoroscopic guidance, and no procedure-related complications—such as infection, hematoma, or chemical neuritis—were observed. While we acknowledge the need for further physicochemical validation, the existing clinical evidence suggests that this mixture can be safely used in carefully controlled procedural settings.

We also agree that the description of the discography procedure could have included more detailed information, such as the injection pressure and contrast volume. As noted in the Methods, a nonionic contrast agent was used solely to confirm needle placement and assess pain provocation. Approximately 1 mL of contrast dye was injected slowly at a rate of 0.5 mL per second to verify accurate intradiscal positioning and evaluate pain response. Epidural spread was indirectly confirmed fluoroscopically, as illustrated in Fig. 2 of [1], which demonstrates dye diffusion toward the anterior aspect of the dura.

Our conclusion emphasized that ISI provides temporary symptomatic relief and may delay the need for surgery for up to 1 year in appropriately selected patients, rather than serving as a definitive or curative intervention. We fully agree that magnetic resonance imaging (MRI) follow-up would offer valuable insight into potential discal changes, and we plan to incorporate such imaging analyses in future prospective studies.

Although concurrent conservative treatments (e.g., medications, physiotherapy) were not strictly standardized, all patients received comparable baseline regimens prior to ISI, and the continuation of these treatments after the procedure reflected routine clinical practice rather than a confounding therapeutic variable. This real-world heterogeneity, while a limitation, also enhances the external validity and clinical applicability of our findings.

We acknowledge that repeated-measures analysis of variance could provide a more robust statistical model for longitudinal pain assessment. However, given that only two postoperative time points (2 and 6 weeks) were analyzed, paired t-tests were deemed statistically sufficient to capture early changes while minimizing model overfitting. Future studies with longer follow-up and additional timepoints will adopt more advanced analytic approaches, including mixed-effects models.

We thank the reader for emphasizing infection surveillance. All procedures were performed under sterile conditions with prophylactic intravenous antibiotics, and all patients were followed up for at least 1 year. No cases of infection, discitis, or subdural injection occurred. Although explicit microbiologic surveillance was not reported, clinical monitoring during follow-up revealed no evidence of post-procedural complications, supporting the safety profile of ISI observed in this cohort.

We fully agree that our results should be interpreted with caution and within the context of current evidence. Indeed, our discussion acknowledged the lack of a control group and standardized technique as key limitations. Nonetheless, this study represents the first clinical series to demonstrate that ISI may yield meaningful short-term improvement in both back and leg pain in patients with lumbar spinal stenosis—especially those with unilateral symptoms and Pfirrmann grade ≥2 degeneration. The finding that 87.7% of patients avoided surgery for at least 1 year highlights ISI’s potential as a bridge therapy between conservative management and surgery.

We concur that prospective randomized controlled trials comparing ISI with epidural steroid injections, incorporating validated functional scales and MRI monitoring, are necessary to establish definitive efficacy and long-term safety.

We are grateful for the reader’s insightful critique, which underscores both the promise and the necessary caution regarding ISI for lumbar spinal stenosis. While acknowledging methodological limitations, we believe our study contributes meaningful preliminary evidence that ISI may serve as a safe, minimally invasive option for temporary pain relief and surgical delay in selected patients. We hope this exchange stimulates further investigation through well-designed prospective trials.