Cervical muscle morphology in women with disc herniation: methodological and interpretative considerations.

This Letter to the Editor responds to the recent case-control study by Dong and colleagues (Eur. J. Radiol. 199 (2026) 112786), which proposed a hierarchical cervical muscular adaptation model in women with disc herniation. While acknowledging the clinical relevance of the question, we discuss seven methodological and interpretative considerations: the limits of causal inference from a retrospective cross-sectional design, the adequacy of the MRI-normal comparator group, the generalisability of a female-only sample, the omission of fat-fraction assessment, the ambiguity of the proposed functional muscle classification, the absence of multiple-comparison correction and inter-observer reliability reporting, and the positioning of the findings within existing literature on cervical paraspinal muscle morphology. We propose specific design features - including prospective longitudinal imaging, volunteer controls, Dixon-based fat fraction, anatomical-functional mapping, and inclusion of functional outcomes - that would strengthen future studies in this important area.