Commentary Flags Statistical Issues in Meningeal Artery Study

A letter to the editor published in the Egyptian Journal of Neurosurgery on September 14, 2026, raises specific methodological concerns regarding a recent anatomical study on the middle meningeal artery and dura mater. The commentary, authored by Naina Kumari, addresses an original article by Oprić et al. that was published on July 17, 2026. While acknowledging the anatomical value of the original research, the letter argues that several statistical and design issues may affect the interpretation and generalizability of the findings. The correspondence highlights the need for caution when applying the study’s quantitative and clinical conclusions to broader medical contexts.

The primary concern identified in the commentary is the potential for pseudoreplication in the histological analysis. The original study collected a total of 627 tissue sections from 50 middle meningeal artery specimens, which were derived from 25 individuals. The letter notes that it is unclear whether the statistical analysis accounted for the fact that multiple specimens and sections originated from the same individual. Using multiple sections from the same participants as independent observations can lead to an overestimation of the sample size. This practice can consequently result in the underestimation of the standard error and may produce false positive results. The commentary suggests that if repeated measurements are used, statistical methods must take into account the within-subject correlation to maintain validity.

Beyond the histological data, the letter addresses the limitations of the clinical component of the original study. The clinical population consisted of only 13 patients, a sample size that can severely restrict statistical power and the reliability of any inferential analysis. This limitation is compounded by the very low number of outcome events observed in the cohort. Specifically, coma occurred in just two patients, and death occurred in just two patients. With such low numbers of events, intergroup comparisons can generate unreliable estimates or associations, particularly when multiple variables are being compared simultaneously. The commentary emphasizes that the clinical association reported in the original article should therefore be considered exploratory and hypothesis-generating rather than confirmatory.

The selection and interpretation of conventional statistical tests in the original study are also questioned based on the limited clinical data available. The letter points out that several variables in the dataset seem to contain very small cell counts. Despite this, the authors of the original study reported using Student’s t-test and Spearman correlations with a significance threshold of p < 0.05. In cases with small cell counts, asymptotic statistical procedures may not perform well, and unadjusted p-values may be misleading. The commentary suggests that using exact statistical methods, reporting effect estimates with confidence intervals, and placing more emphasis on descriptive rather than significance-based interpretation would provide a more robust and transparent analysis.

The middle meningeal artery is of major clinical relevance in the context of epidural hematoma, a condition where the artery plays a significant role. The original authors provided valuable histological observations of the artery and the dura mater, which may have implications for understanding and managing this condition. The commentary commends the authors for covering an anatomically important and relatively underexplored topic. However, the methodological issues raised in the letter deserve further discussion because they may influence how the findings are interpreted and applied in neurosurgical practice.

The correspondence concludes by stating that the methodological considerations do not detract from the anatomical value of the study. Instead, they reflect the need for some caution in the quantitative and clinical interpretation of the findings. The letter suggests that future studies would benefit from treating the individual participant as the primary sampling unit. Additionally, using statistical methods appropriate for clustered observations and sparse data is recommended to ensure more reliable results. This approach would help address the concerns regarding pseudoreplication and low statistical power identified in the current commentary.

Subject of Research: Methodological critique of a histological study on the middle meningeal artery and dura mater

Article Title: Comment on “histology of the middle meningeal artery and the dura mater, and their neurosurgical significance”

Article References: Kumari, N. (2026). Comment on “histology of the middle meningeal artery and the dura mater, and their neurosurgical significance”. Egyptian Journal of Neurosurgery, 41(1), Article 159. https://doi.org/10.1186/s41984-026-00665-0

Image Credits: AI Generated

DOI: 10.1186/s41984-026-00665-0

Keywords: middle meningeal artery, dura mater, histology, statistical methodology, pseudoreplication, epidural hematoma, neurosurgery, clinical research, Egyptian Journal of Neurosurgery, letter to the editor, Comment, middle