Letter to the Editor Regarding “Effects of Desflurane and Propofol General Anesthesia on Postoperative Recovery Quality in Elderly Patients Undergoing Spinal Surgery: A Randomized Non-Inferiority Trial” [Letter]
Abstract
We read with great interest the study by Shi et al, 1 published in Drug Design, Development and Therapy , comparing desflurane-based inhalational anesthesia with propofol-based total intravenous anesthesia (TIVA) in elderly patients undergoing spinal surgery. The authors found that desflurane provided non-inferior postoperative Quality of Recovery-15 (QoR-15) scores, with faster emergence and lower phenylephrine requirements. While acknowledging the clinical relevance of this randomized trial, several methodological and interpretative issues warrant further discussion. First, regarding the analysis population and post-randomization exclusion. Although the abstract reports 109 randomized patients, the Results section and flowchart indicate that 110 patients were randomized, with one patient in the propofol group subsequently withdrawn because of an unplanned postoperative intensive care unit admission. 1 As this clinically important exclusion occurred after randomization, the missing outcome is potentially informative and could be related to prognosis, which may introduce bias in a per-protocol or available-case analysis. The updated Consolidated Standards of Reporting Trials (CONSORT) 2025 guidance emphasizes transparent reporting of which randomized participants are included in each analysis and how missing outcome data are handled. 2 It would therefore be helpful to clarify whether the primary analysis was conducted according to the intention-to-treat principle, and to provide a sensitivity analysis that incorporates this patient’s data, perhaps through multiple imputation or a best-worst case scenario. Second, regarding the non-inferiority margin and the interpretation of “interchangeability”. While we acknowledge that the 6-point margin was based on the minimal clinically important difference, recent methodological