Regarding “Comprehensive Management of Piriformis Syndrome With Endoscopic Release and Sciatic Neurolysis Provides Favorable Outcomes and Low Complication Rate”

I read with great interest the recent study by Quesada-Jimenez et al.1 evaluating outcomes of endoscopic sciatic neurolysis and piriformis release in patients with piriformis syndrome. The authors should be commended for their long-term follow-up, comprehensive diagnostic algorithm, and favorable clinical outcomes. Their work significantly advances the surgical management of this underdiagnosed yet debilitating condition. While the study underscores the value of endoscopic decompression, we believe that further refinement in preoperative diagnostic specificity could enhance surgical decision-making and long-term outcomes. One notable area for potential advancement lies in the integration of quantitative imaging biomarkers, particularly magnetic resonance imaging-based measurements of piriformis hypertrophy or asymmetry. The authors reported piriformis muscle enlargement in over half the cohort, consistent with findings from Lee et al.2 yet stopped short of defining threshold values for surgical candidacy. Establishing normative cross-sectional areas—such as those proposed by Lim et al.3—could provide objective diagnostic anchors that complement the existing clinical algorithm. Secondly, while the authors included diagnostic injections as both therapeutic and confirmatory tools, the sensitivity and specificity of this approach remain variably reported. Some studies suggest that a positive lidocaine response may reflect referred intra-articular or spinal pain rather than true piriformis syndrome.4 We propose that incorporating electromyographic findings or nerve conduction studies into the algorithm, particularly in ambiguous cases, may further stratify surgical candidacy and reduce misdiagnosis. This aligns with recommendations from Park et al.5 emphasizing multimodal diagnostic layering for deep gluteal syndromes. Finally, the study's impressive minimal clinically important difference attainment across multiple patient-reported outcomes highlights the effectiveness of endoscopic decompression. However, future research could examine postoperative objective neuromuscular outcomes, such as hip abduction strength or functional gait analysis. These parameters may provide a more granular understanding of neurovascular recovery beyond subjective scales. In conclusion, the authors’ algorithm offers a strong foundation for clinical diagnosis and management of piriformis syndrome. We advocate for its continued evolution with the integration of quantitative imaging thresholds, electrophysiologic adjuncts, and objective functional metrics to further optimize patient selection and outcomes. The author (J.P.) declares no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.