We read with great interest the recent case report describing staged unilateral biportal endoscopic decompression (ULBD) in a patient with achondroplasia and multilevel lumbar spinal stenosis [1]. The authors are to be commended for successfully addressing a technically demanding scenario and for highlighting important perioperative challenges associated with altered anatomy in achondroplasia. However, we wish to offer several observations and constructive comments that may help contextualize the findings and guide future reports.

First, the authors describe a delayed linear durotomy discovered during the second-stage surgery, which was attributed to dural fragility following decompression. While this interpretation is plausible, alternative explanations should also be considered. In achondroplasia, reduced canal dimensions, shortened pedicles, and dense ligamentum flavum hypertrophy are well-documented risk factors for unrecognized intraoperative dural injury. Prior studies indicate that intraoperative dural tears are not uncommon in endoscopic decompression, with incidences in the low single digits depending on surgeon experience and case complexity [2-4]. Without intraoperative video review or immediate postoperative imaging, it is difficult to conclusively differentiate a “secondary expansion-related durotomy” from a missed intraoperative tear. Moreover, the mechanism of a delayed or secondary dural tear has not been validated, and unrecognized intraoperative injury remains a scientifically plausible alternative [5]. Thus, instead of attributing the event to a single mechanism, a more balanced discussion acknowledging multiple possibilities would strengthen the interpretation.

Second, although the decision to perform staged decompressions was appropriate given the patient’s comorbidities and complex anatomy, the rationale for selecting an endoscopic ULBD approach over conventional laminectomy warrants additional clarification. Endoscopic surgery may reduce paraspinal muscle trauma, minimize blood loss, and facilitate postoperative recovery, factors that are particularly relevant in medically fragile patients or those with challenging anatomic constraints [6-8]. Biportal endoscopy also provides magnified visualization for precise decompression, potentially limiting iatrogenic instability compared with traditional laminectomy. Although conventional laminectomy remains the most established treatment for stenosis associated with achondroplasia [9,10], emerging evidence shows that endoscopic decompression can be performed safely and effectively in carefully selected patients when undertaken by experienced surgeons [7,11]. Stating this explicitly would better place the surgical decision within an evolving evidence-based framework.

Third, the case demonstrates meaningful short-term improvement in pain and motor function, which is encouraging. However, follow-up in the report appears limited to the immediate postoperative period and a one-week review. From a longer-term standpoint, patients with achondroplasia face ongoing risks of restenosis and recurrent claudication due to progressive skeletal dysplasia and canal remodeling [12]. Longitudinal series have shown that, although decompression often leads to durable improvement, reoperation rates remain considerable, underscoring the need for long-term surveillance [13-15]. Therefore, even after technically successful endoscopic decompressions, extended clinical and radiologic follow-up is essential to evaluate the durability of symptom relief and determine whether further intervention is required.

In summary, we commend the authors for presenting their technical experience in a challenging case. At the same time, objective interpretation of intraoperative events, clearer justification of the chosen surgical approach, and acknowledgment of the long-term clinical trajectory are important for situating this case within an appropriate clinical and academic context.