The Spatial Characteristics of Intervertebral Foramina within the L4/L5 and L5/S1 Motor Segments of the Spine

Round 1

Reviewer 1 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

Dear Authors, I thank you for the effort you have made to improve the work.

the topic treated is interesting and actual but there are some issues to discuss:

 

1) please provide a copy of the informed consent

 

2) although the number of patients included is higher (89) i have a concern that is still to little

 

3) please provide the information of the ct scan used and the protocol of the study used

 

4) the aim of the study is still not clear since the lack of literature and the use of the ct only, in my opinion, does not provide enough information about the importance of this measurements. please clarify this statements.

 

 

5) the conclusions of the paper did not provide enough information about the importance of the study please clarify them

Author Response

Dear Reviewer,
Thank you for dedicating your time to thoroughly review our manuscript and for providing insightful feedback. We deeply value your expert perspective and appreciate the constructive points you have raised.

 

1) please provide a copy of the informed consent
 
In our research, a key facet of our ethical approach involved verbal communication with the patients whose CT scans were included in the study. These individuals were explicitly informed that their imaging studies would be stored in an anonymized format, ensuring that no personally identifiable information would be associated with the data, except age and gender. Additionally, they were made aware that these anonymized images might be used for research or educational purposes only. Importantly, imaging studies of patients who did not provide explicit consent were meticulously excluded and not employed for research endeavors.
The nature of our study granted it exemption from the usual requirement to seek consent from the bioethics committee. We want to emphasize that this decision was made with careful consideration for ethical standards, ensuring compliance with regulatory requirements.
Given the robust anonymization measures in place, we made a conscientious choice not to obtain written informed consent from each participant. This decision was grounded in the assurance that the anonymity of patients' personal data was preserved, thus minimizing any potential impact on their privacy.
Once again, we apologize for any confusion and appreciate your diligence in scrutinizing the ethical dimensions of our study. We remain committed to upholding the highest standards of research ethics and are grateful for the opportunity to address these concerns.

 

 

 

2) although the number of patients included is higher (89) i have a concern that is still to little

 Thank you for your insightful comments regarding the sample size of our study. We understand your concern about the increase from 19 to 89 participants potentially being insufficient. However, we would like to present several statistical arguments that support the adequacy of our sample size.
The increase in sample size from 19 to 89 participants significantly enhances the statistical power of our study. This increase allows for a more reliable detection of effect sizes, improving the robustness of our findings. A power analysis based on the initial effect sizes observed with 19 participants suggests that a sample size of 89 provides sufficient power to detect clinically meaningful differences.
An important observation in our expanded dataset is the stability of the mean differences. The maximal difference in means between the initial and the expanded datasets was less than 4%. This minimal variation underscores the consistency and reliability of our findings. It suggests that even with a relatively smaller sample size, our study is capturing a true effect that is not substantially influenced by the increase in sample size.
With the increased sample size, the precision of our estimates, as reflected in the confidence intervals, has improved. Narrower confidence intervals with the larger sample size indicate more precise estimates, adding confidence to the generalizability of our results.
When compared to other studies in our field, the sample size of 89 is within a reasonable range. Many impactful studies in our area of research have been conducted with similar or even smaller sample sizes, yet have provided valuable insights into the topic.
We employed robust statistical methods that are well-suited for our sample size. These methods are designed to maximize the reliability of results even when sample sizes are not large by conventional standards.
Moreover, some similar studies also refer to such small groups Yan, Shuaifeng, et al. "Three-dimensional morphological characteristics of lower lumbar intervertebral foramen with age." BioMed Research International 2018 (2018) (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6252236/ )

In conclusion, although the sample size of 89 may still seem modest, both the stability of our findings upon expanding the sample and the statistical methods employed assure the reliability and validity of our results. We believe that our study makes a meaningful contribution to the field and provides a solid foundation for further research with larger cohorts.

 

 

 

3) please provide the information of the ct scan used and the protocol of the study used

Study Objective: To analyze the morphometry of intervertebral foramina in the lumbar spine, focusing on the L4/L5 and L5/S1 segments.

Population: Participants aged 30-90 years, both genders, experiencing lower back pain. Exclusion criteria include previous spinal surgery or trauma.

CT Imaging Protocol:

Equipment: Use of a multi-detector CT scanner.
Scan Parameters: Slice thickness of 1-2 mm, scan range from L3 to S1.
Patient Positioning: Supine position with neutral spine alignment.
Image Acquisition: Standard lumbar spine protocol.
Morphometric Analysis:

Software: Utilize 3D reconstruction software InVesalius, Meshmixer, 3d Builder, 3D Slider and GOM .
Measurements: Assess foraminal height, width, and area at L4/L5 and L5/S1 in three planes.
Data Handling: Record and analyze data using appropriate software (e.g., SPSS).
Statistical Analysis: Use descriptive statistics and ANOVA for group comparisons. Set significance at p < 0.05.

Ethical Considerations: Exemption from bioethics committee consent and verbal consent from all participants.

Limitations: Note limitations related to CT imaging position and generalizability of findings due to sample characteristics.

 

 

4) the aim of the study is still not clear since the lack of literature and the use of the ct only, in my opinion, does not provide enough information about the importance of this measurements. please clarify this statements.

 Thank you for your comments and the opportunity to clarify the aim and methodology of our study. Our research focuses on assessing the morphometry of intervertebral canals in the lumbar spine, specifically at the L4/L5 and L5/S1 motor segments, using CT imaging. The objective is to determine how morphometric parameters are influenced by factors like age and sex.
We selected CT imaging due to its superior ability to visualize bony structures, which is essential for accurate morphometric analysis. While acknowledging the value of other imaging modalities like MRI, CT provides the necessary detail for the specific focus of our study.
Our study addresses a gap in the literature regarding quantitative assessment of intervertebral foramina sizes. We aim to supplement the existing knowledge with new data, particularly considering the variability due to age and sex, which has been less explored in current research.
Understanding the morphometric variations of intervertebral foramina has significant implications for both diagnostic and therapeutic strategies in spine pathologies. Our findings can potentially aid in refining diagnostic criteria and surgical approaches.
We appreciate your insightful feedback and hope this response clarifies the intent and significance of our study. We believe our research will make a meaningful contribution to the field of spinal pathology and treatment.

The main objectives of the study on the spatial characteristics of intervertebral foramina in the context of lumbar foraminal stenosis are as follows:
To assess the morphometry of the intervertebral canals in the lumbar spine at the level of the L4/L5 and L5/S1 motor segments.
To determine the influence of the patient's age and sex on the morphometric parameters of the intervertebral canals at the L4/L5 and L5/S1 levels.
To establish relationships between the circumference and the surface area on individual cross-sections of the intervertebral canals at the L4/L5 and L5/S1 levels.
To improve the conservative and surgical treatment of spinal diseases by gaining a better understanding of the pathology of the lumbar spine.

 

 

5) the conclusions of the paper did not provide enough information about the importance of the study please clarify them

We have corrected the Conclusions.

Reviewer 2 Report (Previous Reviewer 3)

Comments and Suggestions for Authors

The authors submitted the revised manuscript.

(1)

In the part of the Materials and Methods, the authors are describing that “This study included individuals with of lower back pain, who had undergone lumbar spine CT.

As I raised as one of the issues to the original manuscript, lumbar foraminal stenosis (LFS) are generally thought to cause lower limb pain mainly, not low back pain. 

The authors need to address this issue.

 

(2)

It is widely known that the patients usually suffered from low back pain when they are at standing position.

I assumed that images of lumbar spine CT that authors analyzed had been taken in supine position.

Because of the fact above and other factors, the aim of the study is still ambiguous.

The authors need to address this issue and clarify the clinical relevance of the study.”

 

The revised manuscript in still not considered to be suitable for publication in Applied Sciences unless these issues above are resolved in a convincing way.

Author Response

Dear Reviewer,
Thank you for dedicating your time to thoroughly review our manuscript and for providing insightful feedback. We deeply value your expert perspective and appreciate the constructive points you have raised.

(1) In the part of the Materials and Methods, the authors are describing that “This study included individuals with of lower back pain, who had undergone lumbar spine CT. As I raised as one of the issues to the original manuscript, lumbar foraminal stenosis (LFS) are generally thought to cause lower limb pain mainly, not low back pain. The authors need to address this issue.

Thank you for your valuable comments. We acknowledge your concern regarding the inclusion of patients with lower back pain in our study, especially given that lumbar foraminal stenosis (LFS) typically manifests with lower limb pain.

It is important to clarify that the primary aim of our study was not to examine LFS specifically, but rather to analyze the morphometry of the intervertebral foramen in different cross-sections, particularly in the L4/5 and L5/S1 segments.
We included patients with lower back pain as a broader category to investigate the morphology of intervertebral foramina in a general population that might be at risk for spinal issues, including but not limited to LFS. This approach allows us to provide a comprehensive overview of the intervertebral foramen morphology in a diverse patient population.
We are aware that including patients with established LFS might have biased the morphometric measurements. Therefore, we deliberately chose a population with lower back pain symptoms rather than confirmed LFS to avoid such bias and to ensure that the morphometric variations observed were not exclusively related to LFS pathology.
By analyzing a more generalized population, our study aims to contribute to a broader understanding of spinal pathologies. The measurements and comparisons made between the L4/5 and L5/S1 segments are intended to enhance the knowledge base regarding spinal canal morphology, which could be beneficial in various clinical contexts.

We hope this response addresses your concerns and clarifies the rationale behind our study design. We believe our research provides valuable insights into spinal morphometry that can aid in the diagnosis and treatment of a range of spinal 

 

 (2) It is widely known that the patients usually suffered from low back pain when they are at standing position. I assumed that images of lumbar spine CT that the authors analyzed had been taken in supine position. Because of the facts above and other factors, the aim of the study is still ambiguous. The authors need to address this issue and clarify the clinical relevance of the study.”

The main objectives of the study on the spatial characteristics of intervertebral foramina in the context of lumbar foraminal stenosis are as follows:
To assess the morphometry of the intervertebral canals in the lumbar spine at the level of the L4/L5 and L5/S1 motor segments.
To determine the influence of the patient's age and sex on the morphometric parameters of the intervertebral canals at the L4/L5 and L5/S1 levels.
To establish relationships between the circumference and the surface area on individual cross-sections of the intervertebral canals at the L4/L5 and L5/S1 levels.
To improve the conservative and surgical treatment of spinal diseases by gaining a better understanding of the pathology of lumbar foraminal stenosis.

 Studies have shown that while there are changes in the dimensions of the lumbar spinal canal and intervertebral foramen between different positions, these changes are generally consistent and can be accounted for in the analysis. For instance, a study published by Zhang et al. (https://www.nature.com/articles/s41598-018-26077-1) focused on the changes in L4/5 intervertebral foramen bony morphology with age, demonstrating how morphological changes occur primarily in the ventro-dorsal direction and are consistent across different age groups. This suggests that while body position can affect the morphology of intervertebral foramina, the changes are predictable and can be considered in interpreting the results. Therefore, our study's use of CT imaging in a supine position remains valid for the morphometric analysis of the lumbar spine, providing reliable and clinically relevant data.

These limitations of the study are described in the section of the discussion.

Reviewer 3 Report (Previous Reviewer 2)

Comments and Suggestions for Authors The Article Title "Spatial characteristics of intervertebral foramina within L4/L5 and L5/S1 motor segments of the spine" Piotr Nowak, Mikołaj Dąbrowski , Adam Druszcz , Łukasz Kubaszewski. Congratulations  for all authors. Thank You for adding new information - suplementary files and non-published material. The main question addressed by the research is clear. The topic is original  and it add new information. It seems that no specific improvements should the authors consider regarding the methodology. The conclusions consistent with the evidence and arguments and  they address the main question. The references are appropriate. The tables and figures clear ilustrated the topic.  

 

Author Response

Dear Reviewer,
Thank you for dedicating your time to thoroughly review our manuscript and for providing  feedback. We deeply value your expert perspective and appreciate the constructive assemsment you have raised.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors: thank you for giving me the opportunity to participate in the review of this article, Although the topic discussed is very interesting and highly relevant, I cannot recommend the publication of this study for many reasons.

The study aims to assess the morphometry of the intervertebral canals in the lumbar spine at the specific levels of L4/L5 and L5/S1 motor segments. However, it does not provide information on the sample size, or the population characteristics involved in the study. Without this context, it is challenging to generalize the findings to the wider population.

The study mentions correlations between the circumference and surface area of individual cross-sections of the intervertebral canals. It is unclear whether these correlations refer to the lumbar spine as a whole or specifically to the L4/L5 and L5/S1 levels. Clarification is needed to ensure accurate interpretation of the findings.

The study suggests assessing the influence of age and sex on the morphometric parameters of the intervertebral canals. While age and sex can be potential factors, it is important to conduct a power analysis to determine the appropriate effect size and to account for confounding variables. Without specifying how these factors were assessed or controlled in the study, it becomes challenging to obtain a reliable correlation. Proper consideration and adjustment for confounding variables are crucial for accurate interpretations.

   Although the results section mention statistical significance, the materials and methods section does not discuss it. It is not possible to ascertain which analyses were performed and, consequently, how to assess the significance. The sample size is very small and heterogeneous in terms of age and sex, posing a high risk that the obtained data may not be representative of the cohorts. I suggest significantly expanding the sample based on a proper pilot study and the findings of an adequate power analysis.

Author Response

Dear Reviewer, 

 

Thank you for taking the time to review our manuscript and for your constructive feedback. Below I would like to present our answers to the issues raised by you in your review.

 

• The study aims to assess the morphometry of the intervertebral canals in the lumbar spine at the specific levels of L4/L5 and L5/S1 motor segments. However, it does not provide information on the sample size, or the population characteristics involved in the study. Without this context, it is challenging to generalize the findings to the wider population.

 

Requested information is included in the chapter Materials and methods:  

“The research was conducted on a population of 19 patients (six women and 13 men) of W. Dega University Hospital in Poznan [15]. The oldest participant was 78 years old and the youngest 40 years old”

 

The small number of samples in our study was due to the use of restrictive inclusion criteria, which aimed to select patients who would fit the purpose of our study. We wanted to investigate the relationship between the sagittal alignment of the spine and the quality of life in patients with chronic low back pain. Therefore, we applied the following exclusion criteria: scoliosis, asymmetry of the position and shape of the pelvis, and root symptoms. These criteria were applied to ensure that the patients had similar anatomical characteristics and spinal pathologies, and to avoid confounding factors that could affect the measurement results.

 

We acknowledge that this was a limitation of our study, and we have stated this clearly in the discussion section of our manuscript. We also suggested that further research is needed in this area, taking into account a larger and more diverse population. We believe that our study provides a useful insight into the topic, and that it can serve as a basis for future studies.

 

We hope that this explanation clarifies our rationale for choosing a small number of samples in our study. 

 

• The study mentions correlations between the circumference and surface area of individual cross-sections of the intervertebral canals. It is unclear whether these correlations refer to the lumbar spine as a whole or specifically to the L4/L5 and L5/S1 levels. Clarification is needed to ensure accurate interpretation of the findings.

 

The correlations between the circumference and surface area of individual cross-sections of the intervertebral canals refer specifically to the L4/L5 and L5/S1 levels, as these were the segments that were measured and analyzed in our study. We apologize for any confusion that may have arisen from our wording. We have revised the sentence in the abstract to clarify this point:

 

“The obtained results showed correlations between the circumference and the surface area on individual cross-sections of the intervertebral canals at the L4/L5 and L5/S1 levels.”

 

We hope this addresses your concern

 

• The study suggests assessing the influence of age and sex on the morphometric parameters of the intervertebral canals. While age and sex can be potential factors, it is important to conduct a power analysis to determine the appropriate effect size and to account for confounding variables. Without specifying how these factors were assessed or controlled in the study, it becomes challenging to obtain a reliable correlation. Proper consideration and adjustment for confounding variables are crucial for accurate interpretations.

 

We agree with you that age and sex can be potential factors that may affect the morphometric parameters of the intervertebral canals. We also acknowledge that it is important to conduct a power analysis to determine the appropriate effect size and to account for confounding variables. However, due to the limited availability of data and resources, we were not able to perform such an analysis in our study. We have stated this as a limitation of our study in the discussion section of our manuscript.

 

We have assessed the influence of age and sex on the morphometric parameters of the intervertebral canals by using  Mann-Whitney U-test.. We have reported the results of these models in the results section of our manuscript, along with the corresponding p-values and confidence intervals. We have also provided scatter plots and correlation coefficients to illustrate the relationship between age, sex, and the morphometric parameters of the intervertebral canals in the supplementary materials.

 

We believe that our study provides a useful insight into the topic, and that it can serve as a basis for future studies that will include a larger and more diverse sample size, a more rigorous power analysis, and a more comprehensive adjustment for confounding variables. We hope that this explanation clarifies our rationale for choosing our methods and presenting our results.

 

•  Although the results section mention statistical significance, the materials and methods section does not discuss it. It is not possible to ascertain which analyses were performed and, consequently, how to assess the significance. The sample size is very small and heterogeneous in terms of age and sex, posing a high risk that the obtained data may not be representative of the cohorts. I suggest significantly expanding the sample based on a proper pilot study and the findings of an adequate power analysis.

 

We apologize for the lack of clarity in the Materials and Methods section regarding the statistical analyses that we performed. We have revised this section to include more details and explanations about the tests that we used and the criteria that we followed to assess the significance.

 

“The analysis used Statistica software (Version 13.0, StatSoft Inc., Tulsa, OK, USA). To compare the impact of various factors on measurements of  the intervertebral foramen , we used a Mann-Whitney U-test (p<0.05). In addition, we determined the Spearman’s rank correlation between measurements of  the intervertebral foramen.“

 

We acknowledge that our sample size was very small and heterogeneous in terms of age and sex, and that this poses a high risk that the obtained data may not be representative of the cohorts. We have stated this as a limitation of our study in the discussion section of our manuscript. We also explained that our sample size was determined by the availability of patients who met our inclusion criteria, which were as follows: chronic low back pain lasting more than six months, no history of spinal surgery or trauma, no signs of infection or tumor, and no contraindications for magnetic resonance imaging (MRI).

 

We agree with you that it would be desirable to expand our sample based on a proper pilot study and the findings of an adequate power analysis. However, due to the limited resources and time constraints, we were not able to conduct such a study in our current project. We have suggested that further research is needed in this area, taking into account a larger and more diverse sample size, a more rigorous power analysis, and a more comprehensive adjustment for confounding variables. We hope that this explanation clarifies our rationale for choosing a small number of samples in our study. 

 

Your feedback is invaluable to us in refining our work and its presentation. Once again, thank you for your insightful comments. 

 

Best Regards,

Mikolaj Dabrowski

Reviewer 2 Report

Comments and Suggestions for Authors The Article Title: "Spatial characteristics of intervertebral foramina within L4/L5 and L5/S1 motor segments of the spine" The aim of the study is to assess the morphometry of the intervertebral canals in the lumbar spine at the level of the L4/L5 and L5/S1 motor segments. The main question addressed by the research is clear. The topic is original  and it add new information. It seems that no specific improvements should the authors consider regarding the methodology. The conclusions consistent with the evidence and arguments and  they address the main question. The references are appropriate. The tables and figures clear ilustrated the topic.  

 

Author Response

Dear Reviewer,

We are grateful for your encouraging feedback on our study. We sincerely appreciate the time and effort you dedicated to reviewing our manuscript.

Your positive comments are motivating and affirm the value of our research. We are delighted that you recognize the potential impact of our work and the significance of our findings. 

 

We will continue to strive to meet high research standards and aim to contribute further to our field. Once again, we express our heartfelt thanks for your constructive and affirming review.

Best Regards,

Mikolaj Dabrowski

Reviewer 3 Report

Comments and Suggestions for Authors

By performing this study, the authors assessed the morphometry of the intervertebral canals in the lumbar spine at the level of the L4/L5 and L5/S1 motor segments.

This study is well-written and interesting.

However, this study has several issues such as listed below.

The authors need to perform revision of the manuscript by addressing the issues listed below in a convincing way to be suitable for publication in Applied Sciences.

 

Revise point/

(1)   It is not clear how the authors selected samples of 19 patients. Also, I do not think the sample number (19) in this study is not enough for this kind of study. The authors need to address this issue.

(2)   In the first part of the abstract, the authors are describing that “The prevalence of low back pain in the population requires more and more accurate diagnostic methods to more effectively prevent and treat patients with these ailments. In this paper, we focused on one of the causes of low back pain - lumbar foraminal stenosis (LFS).”  In general, LFS are thought to cause lower limb pain mainly, not low back pain. The authors need to address this issue.

(3)   The aim of the study is quite ambiguous. The authors need to clarify the clinical relevance of the study.

Author Response

Dear Reviewer, 

We would like to express our gratitude for the time and effort you have put into reviewing our manuscript. Your comments and suggestions are invaluable to improving the quality and clarity of our work. We appreciate your thoughtful and constructive feedback and are writing to address the concerns you raised.

• (1)   It is not clear how the authors selected samples of 19 patients. Also, I do not think the sample number (19) in this study is not enough for this kind of study. The authors need to address this issue.

 

We appreciate your concern regarding the selection process for our study participants and the sample size.

The small number of samples in our study was due to the use of restrictive inclusion criteria, which aimed to select patients who would fit the purpose of our study. We wanted to investigate the relationship between the sagittal alignment of the spine and the quality of life in patients with chronic low back pain. Therefore, we applied the following exclusion criteria: scoliosis, asymmetry of the position and shape of the pelvis, and root symptoms. These criteria were applied to ensure that the patients had similar anatomical characteristics and spinal pathologies, and to avoid confounding factors that could affect the measurement results.

We acknowledge that this was a limitation of our study, and we have stated this clearly in the discussion section of our manuscript. We also suggested that further research is needed in this area, taking into account a larger and more diverse population. We believe that our study provides a useful insight into the topic, and that it can serve as a basis for future studies.

 

We hope that this explanation clarifies our rationale for choosing a small number of samples in our study. 

 

• (2)   In the first part of the abstract, the authors are describing that “The prevalence of low back pain in the population requires more and more accurate diagnostic methods to more effectively prevent and treat patients with these ailments. In this paper, we focused on one of the causes of low back pain - lumbar foraminal stenosis (LFS).”  In general, LFS are thought to cause lower limb pain mainly, not low back pain. The authors need to address this issue.

We acknowledge the need for clarity in our description of the relationship between lumbar foraminal stenosis (LFS) and low back pain and lower limb pain.

As you correctly pointed out, LFS is typically associated with lower limb pain due to nerve root compression. However, it can sometimes coexist with low back pain, which can complicate the clinical picture. In the revised manuscript, we will provide a clearer explanation regarding the correlation between LFS and low back pain and lower limb pain. We will also emphasize the potential for LFS to present with concurrent lower limb pain, which is the more common symptom.

We greatly appreciate your insightful comments which help us refine the focus of our study and improve the clarity of our manuscript.

 

• (3)   The aim of the study is quite ambiguous. The authors need to clarify the clinical relevance of the study.

 

We realize from your comments that we need to make these aspects more explicit.

Our study aims to examine the morphometry of the intervertebral foramina in the lumbar spine, specifically at the L4/L5 and L5/S1 motor segments. The objective is to deepen our understanding of lumbar foraminal stenosis (LFS) and how it may contribute to low back pain and lower limb symptoms, which can often coexist.

The Morphological differences may have implications for the biomechanical function and clinical outcomes of the L4/5 and L5/S1 segments. For example, a smaller intervertebral foramen may increase the risk of nerve root impingement and irritation, especially in the presence of degenerative changes such as disc herniation, facet joint hypertrophy, or osteophyte formation. A smaller intervertebral foramen may also limit the blood supply and oxygen delivery to the nerve root, which may impair its function and regeneration. A smaller intervertebral foramen may also reduce the range of motion and flexibility of the segment, which may affect its stability and load distribution

From a clinical standpoint, this research is significant because it has potential to enhance diagnostic precision in identifying LFS, which can be a complex and multifactorial issue. It also may help clinicians devise more effective prevention strategies and treatments for patients suffering from conditions related to LFS. 

In light of your feedback, we will make sure to revise our manuscript to more clearly articulate the aim of our study and its clinical implications. 

We appreciate your insight in helping us improve our work and its presentation. 

We hope these clarifications address your concerns. We sincerely thank you for helping us improve the quality and clarity of our manuscript.

 

Best Regards,

Mikolaj Dabrowski

Reviewer 4 Report

Comments and Suggestions for Authors

Figures 1, 2, and 3 are very confusing (in demonstrating the measurements) and they lack visual clarity

Author Response

Dear Reviewer,

Thank you for dedicating your time to thoroughly review our manuscript and for providing insightful feedback. We deeply value your expert perspective and appreciate the constructive points you have raised. 

 

• Figures 1, 2, and 3 are very confusing (in demonstrating the measurements) and they lack visual clarity

In response to the specific concerns you highlighted, we present modified versions of figures from our manuscript below. The manuscript will be updated with them.

For Figure 3, we've added a reference to the animation in the supplementary in the description for greater clarity

Thank you once again for your contribution to refining our research. We believe your suggestions have greatly enhanced the quality and impact of our work.

 

Best Regards,

Mikolaj Dabrowski

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,

I thank you for the effort you have made to improve the work. However, I cannot accept a study with such a low number of cases and significant heterogeneity regarding gender and age groups. This kind of studies requires an adequate number of cases to have scientific validity. Although the premises are interesting, without a sufficient increase in the sample size, I will not be able to accept the work.

While I understand the difficulties in gathering data and the costs of research projects, these reasons cannot justify the acceptance of a scientific work that should be based on a solid scientific design and an adequate number of samples to lead, as much as possible, to clear scientific evidence aimed at advancing knowledge.

Best Regards

Reviewer 3 Report

Comments and Suggestions for Authors

The authors revised the manuscript.

(1)

To the original manuscript, I raised the issue described below.

“It is not clear how the authors selected samples of 19 patients. Also, I do not think the sample number (19) in this study is not enough for this kind of study. The authors need to address this issue.”

 

Even in this revised manuscript, the authors are not describing how they selected these patients.

For example, they are not describing how they diagnosed that these patients have lesion at L4/L5 and L5/S1 segment of the spine.

 

(2)

To the original manuscript, I also raised the issues described below.

“In the first part of the abstract, the authors are describing that “The prevalence of low back pain in the population requires more and more accurate diagnostic methods to more effectively prevent and treat patients with these ailments. In this paper, we focused on one of the causes of low back pain - lumbar foraminal stenosis (LFS).”  In general, LFS are thought to cause lower limb pain mainly, not low back pain. The authors need to address this issue.”

“The aim of the study is quite ambiguous. The authors need to clarify the clinical relevance of the study.”

 

In this revised manuscript, the authors have added some description in the introduction section, but not in the discussion section at all.

Overall, the issues I raised are not addressed adequately in this revised manuscript.

Furthermore, the authors are not describing information regarding the part (page XX, line XX etc.) they made corrections in the revised manuscript.

 

Taken together, this manuscript in not considered to be suitable for publication in Applied Sciences.