To the Editor, I was interested to read the article by Tran et al. published in the July 2010 issue of the Journal. The authors are to be credited for dealing with the challenges of determining the current best evidence for nonsurgical interventions for lumbar spinal stenosis (LSS). However, based on limitations of the cited publications, the conclusions that can be drawn are limited. Regardless of how the evidence was compiled, if the underlying studies themselves are flawed, the resultant reviews based on that evidence are limited with respect to the conclusions and inferences that can be drawn for treating patients with this unfortunate pain complex. Lumbar spinal stenosis is a clinical syndrome of buttock or leg pain, with or without back pain, and it is associated with decreased lumbar spinal canal space. There are no specific criteria to diagnose this condition. The heterogeneity of LSS symptoms has been well analyzed. Clinically, neurogenic claudication (NC) is considered to be a specific feature; the frequency of NC varies from 23% to 94% depending on the selection criteria and the definition used. Pain observed with NC is often poorly localized with no correlation to central or lateral canal narrowing. In the study by Goh et al., 62% of patients had back pain and 61% of patients had NC. Predominant back pain has other possible diagnoses, including spondylolisthesis, which is considered by many to be a confounding factor that should be excluded from the analyses. In the review by Tran et al., no study was excluded on the basis of the definition of intervention allocation or primary and secondary outcomes. Only three of the reported studies included under epidural anesthesia used fluoroscopic guidance. Incorrect needle placement with non-fluoroscopically-guided epidural analgesia could be as high as 30%. In two studies, neurogenic claudication was not considered for inclusion criteria. Cuckler et al. reported a lumbar epidural approach without fluoroscopy. Surprisingly, a second epidural was given for ethical reasons and not technical failures. In the only positive study evaluating calcitonin, a crossover design was used after a two-month washout period. Findings included a decrease in pain scores for three months. In Group 1 (placebo), there was a trend towards decreased pain scores, even after three months. It is difficult to evaluate the pharmacodynamics of a medication in patients with chronic pain, especially with drugs having unknown mechanisms of action, including epidural steroids. Even in patients with LSS, prolonged effects are possibly associated with changes in central nervous system dynamics. The guidelines advanced by Watters et al. seem to differ from those published in the review by Tran et al., both for calcitonin and epidural steroids.