Dear Editor, We read with interest the randomized controlled trial by Wang et al1 investigating diprospan as an adjunct to ropivacaine for pre-incisional infiltration in pediatric craniotomy. This study addresses an important aspect of perioperative care in a vulnerable population. These noteworthy findings could be of great value in the treatment and management of pediatric neurosurgical patients, potentially offering a simple strategy for improving postoperative comfort. We appreciate that the authors have acknowledged several key limitations of their discussion. To further strengthen the manuscript and guide clinical interpretation, we believe that these acknowledged limitations warrant more detailed elaboration regarding their potential impact on the study’s conclusions of the study. First, regarding the lack of blinding, the authors correctly identified the visible drug differences and the consequent risk of performance bias. This is indeed the study’s most critical methodological constraint2. We encourage a more explicit discussion of how the inability of blinded surgeons and anesthesiologists might have specifically influenced intraoperative decisions (e.g., remifentanil titration) and postoperative analgesic prescriptions, thereby potentially affecting the primary and secondary outcomes. A deeper exploration of this bias would help readers contextualize the reported effect sizes. Second, concerning safety assessment, the authors focused on perioperative outcomes and the need for long-term data. However, the statement of “no adverse effects” would be more informative if discussed in direct relation to the specific glucocorticoid-related risks that were not systematically monitored3,4. Clarifying the scope and duration of safety monitoring performed would provide a clearer framework for the risk-benefit evaluation claimed. Third, pertaining to outcome assessment, the authors appropriately highlighted the reliance on the mCHEOPS scale and its potential limitations, especially for older children. This acknowledgment directly supports our concern that a single, observer-based scale may not fully capture the analgesic profile5,6. The authors’ suggestions for future research to combining these tools are well noted. In the current manuscript, we briefly discussing how this measurement limitation might have influenced the results (e.g., potential for underestimation or overestimation of pain in certain subgroups), which would add valuable nuance. Finally, while the sample size is acknowledged in the context of future dose-finding studies, the implications for the presented subgroup analyses could be addressed more directly. Explicitly stating that these analyses are underpowered and exploratory in nature would prevent overinterpretation. We commend the authors for this preliminary investigation. A more nuanced discussion of these limitations, particularly regarding the concrete implications of unblinding, the scope of safety monitoring, and the choice of endpoint/analysis, would strengthen the manuscript and provide a more balanced, scientifically rigorous perspective for readers.
Deng et al. (Wed,) studied this question.