Response to the letter to the editor: Efficacy of gabapentin and pregabalin for the treatment of neurogenic claudication in lumbar spinal stenosis: a double-blind randomized placebo-controlled trial

Article information

Asian Spine J. 2026;20(3):625-626

Publication date (electronic) : 2026 June 25

doi : https://doi.org/10.31616/asj.2026.0088.r2

Chatupon Chotigavanichaya, Korawish Mekariya, Borriwat Santipas, Sirichai Wilartratsami, Ekkapoj Korwutthikulrangsri, Monchai Ruangchainikom, Panya Luksanapruksa

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Corresponding author: Panya Luksanapruksa Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok 10700, Thailand Tel: +66-2-419-7529, Fax: +66-2-419-7961, E-mail: cutecarg@yahoo.com

Received 2026 February 3; Accepted 2026 March 10.

Dear Editor and authors,

We appreciate your interest in our publication [1] and are grateful for these thoughtful concerns. First, all participants received the same background regimen, structured physiotherapy and naproxen 250 mg twice daily throughout the study period, and no additional pain interventions or medications were permitted. This protocol was adopted for ethical reasons, as prior reports have shown limited symptomatic benefit of gabapentinoids in patients with lumbar spinal stenosis (LSS) [2,3], and prescribing these agents as the sole intervention could have been inappropriate. In addition, our objective was pragmatic, to evaluate whether gabapentin (GBA) or pregabalin (PGB) provides incremental benefit when added to usual first-line care rather than as monotherapy. We agree that co-interventions, and potential variability in adherence to background therapy, may have attenuated between-group differences; accordingly, we noted in the Discussion that any potential effects and adverse events of gabapentinoids could be confounded by concomitant naproxen, and the findings should be interpreted with caution. The fixed titration to target doses over 14 days, followed by maintenance, was chosen to preserve blinding, standardize the intervention across treatment groups, and support trial feasibility. However, we acknowledge that rapid titration may increase adverse effects, particularly in older patients. Titration to the lowest effective dose may therefore be preferable in clinical practice, and future studies using individualized effective dosing and titration strategies should be performed to better define efficacy and safety.

Second, adverse events were prospectively assessed at each visit with predefined discontinuation criteria for intolerance; dizziness and sedation were more frequent with GBA and PGB than placebo, consistent with known class effects, and no participant who attended follow-up withdrew because of adverse events. We acknowledge that 17 participants were lost to follow-up and that specific reasons were not available for all cases, which limits definitive inference regarding tolerability; nevertheless, the observed adverseevent imbalance and the absence of superiority over placebo across efficacy outcomes support our overall conclusion within the trial design. In addition, we also recognize that anatomical heterogeneity in LSS may influence treatment response. We did not stratify the randomization by stenotic level, site, or radiographic severity, because prior studies suggest that clinical symptoms and patient-reported outcomes do not consistently correlate with radiographic severity and that some individuals with radiographic stenosis may be asymptomatic [4-8]. Although baseline number of stenotic level, pain, walking distance, and Swiss Spinal Stenosis Questionnaire scores did not differ significantly between groups, we agree that differences in anatomical phenotype could still affect the efficacy of gabapentinoids, and achieving anatomical homogeneity in LSS population is challenging, still, it should be considered in future studies.

Finally, we agree with the authors that neurogenic claudication is multifactorial. A previous study reported that neuropathic pain was more common in patients with radicular pain, whereas only 15.6% of patients in the predominant neurogenic claudication group had neuropathic pain [9]. Therefore, because we did not use neuropathic pain screening tools and our inclusion criteria was predominant, persistent neurogenic claudication, the observed efficacy GBA and pregabalin PGB in our cohort may have been limited. Nevertheless, identifying patients with LSS who have a predominant neuropathic pain phenotype, and who may benefit from gabapentinoids, remains important, and further studies should evaluate treatment efficacy in this subgroup. In summary, we appreciate these important points, and we believe our findings remain clinically informative for the pragmatic question studied.