The Evidence-Based Spine-Care Journal reviewers were very favorable on the methodology employed by the authors and wished to congratulate them on their work, which mainly serves to underscore the lack of insight that we have accumulated on the question of adjacent segment pathology emerging after elective lumbar fusions.Weaknesses of the study include absence of articles published since 2013, of which there were several, and the absence of a length of follow-up stratification. Merits include the use of a formal grading system of the quality of articles that met inclusion criteria in form of the MINORS system proposed by Wright et al[1] and a thoughtful discussion of the differences of radiographic and clinical manifestations of adjacent disc degeneration. Using the terms adjacent segment degeneration versus adjacent segment disease is a very important distinction to make and one that continues to be underappreciated in our literature. The question of biomechanical and intrinsic biologic etiologies can, of course, not be conclusively answered with the current literature base. As the authors eloquently stated, our current body of literature presents as a “challenging mass of covariables,” and they could have just as justifiably called it a “challenging mess of covariables.” The Evidence-Based Spine-Care Journal/Global Spine Journal wholeheartedly joins the authors in standardizing reporting and differentiation of radiographic and clinical symptoms reporting and using a more meaningful comprehensive assessment menu of variables that possibly play a role in adjacent segment pathology development—including spinal column balance in sagittal and coronal planes, body mass, connective tissue disorders, metabolic factors, as well as contributory medications and of course neurologic and activity status—aside from an emphasis on surgical techniques used.