We read with great interest the article by Chotigavanichaya et al. [1]. The authors are to be commended for conducting a high-quality study. Despite these contributions, certain methodological considerations deserve attention.

Firstly, participants received naproxen and structured physiotherapy, which may have obscured any additional benefit of gabapentinoids, and the absence of detailed reporting on nonsteroidal anti-inflammatory drugs duration, adherence, stopping rules, and related adverse events further limits interpretation, particularly in older adults. Although adverse events were described as tolerable, they occurred in most actively treated patients and 17 participants were lost to followup without explanation, raising uncertainty about true tolerability [2].

Neurogenic claudication is multifactorial, yet the study did not employ neuropathic pain screening tools to identify patients with a predominant neuropathic component who might preferentially benefit from gabapentinoids, and the mandated rapid escalation to fixed target doses within 14 days without allowance for halting titration upon early clinical response deviates from usual practice of individualizing therapy to the lowest effective dose, a strategy that in this older cohort may have contributed to higher rates of dizziness and sedation and potentially obscured benefit in early responders, as dose- or response-stratified analyses and more gradual titration schedules might have yielded different tolerability, adherence, and efficacy outcomes.

The cohort in this study is anatomically heterogeneous, with varying numbers of affected levels and differing central canal and lateral recess severity, yet no prespecified stratification or subgroup analyses were performed; this weakens the post hoc claim that null results reflect predominantly mechanical pathology rather than differential responses across anatomical phenotypes [3,4].

While the study offers valuable randomized data, attention to co-interventions, titration strategy, and anatomical heterogeneity is essential before concluding that gabapentinoids lack benefit in neurogenic claudication, as these factors may influence treatment response and clinical applicability.