Shifting Paradigms in Spinal Infection Management: The Rising Role of Spine Endoscopy—A Systematic Review and Case Series Analysis

Round 1

Reviewer 1 Report (Previous Reviewer 3)

Comments and Suggestions for Authors

Thank you to the authors for completing this study and for their submission.

 

 

Please see and reply to all comments in the PDF attached.

Comments for author File: Comments.pdf

Author Response

Thank you for your critical feedback. We have revised the introduction and discussion sections, made corrections to the formatting, and conducted an additional statistical analysis.

Reviewer 2 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

Some of my previous points were not adequately addressed or not addressed at all.

You talk about spinal infection without refering to mycobacterium tuberculosis, you diagnose a spondylodiscitis in your first case with an MRI without referring the contrast and the sequences or providing any pictures etc. 

Furthermore the upper screws in Figure 9 go through the ribs, maybe remove the picture.

In the limitations of the endoscopic procedure I would refer to the excessive use of Tachosil as there are not many ways of reaction in cases of dural tear and/or excessive bleeding.

 

Author Response

Thank you for your feedback. We have revised the discussion section for improved clarity. Regarding Figure 9, we acknowledge that it gave the misleading impression that the stabilization involved the ribs; this has been corrected.

As for the second point, we included the most illustrative scans for this case. According to our protocol, patients with suspected infection receive contrast during MRI examinations, and this was adhered to in this case.

Round 2

Reviewer 1 Report (Previous Reviewer 3)

Comments and Suggestions for Authors

Thank you to the authors for completing this peer review and for their resubmission.

 

Please see and reply to all comments in the PDF attached.

Comments for author File: Comments.pdf

Author Response

Thank you for your thorough reassessment of our manuscript and for your positive feedback on the introduction, methodology, results presentation, and conclusions. We appreciate your constructive comments and the opportunity to further refine our work.

Reviewer 2 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

The authors revised the manuscript addressing some of the points the were asked and improving the presentation of their statistical analysis.

I still have some wishes:

Please add the approval number of the ethic committee. The fact that it is a retrospective study, gives us not the right to use the data of the patients without approval.

For the third time, M.Tuberculosis is the number one cause in the developing countries and almost in every study you cited. Still you didnt even mention it.

The limitations of the study are usually at the end of the text, just before the conclusion. So move the part 372-408 to the end of the discussion, it is more appropriate there.

 

Author Response

Dear Reviewer,

 

Thank you for your detailed feedback and for recognizing the improvements we have made in response to the previous reviews. We appreciate your continued efforts to help us refine our manuscript.

 

We have addressed your remaining concerns as follows:

1. Ethics Approval Number: We have now added the approval number for the ethics committee exemption in the manuscript, as requested.

2. M. Tuberculosis: We acknowledge your concern regarding the omission of M. Tuberculosis. We have now incorporated this information into the revised manuscript, ensuring that its relevance is adequately addressed in relation to the cited studies.

3. Placement of Limitations Section: We agree with your suggestion regarding the positioning of the limitations section. We have now moved the relevant text (lines 372-408) to the end of the discussion, just before the conclusion, for better coherence.

 

Thank you again for your valuable comments. We hope that these revisions address your concerns and bring the manuscript to the required standard.

 

Round 3

Reviewer 2 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

I think now it is much better. Thank you for your patience.

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

The authors try to underline the importance of endoscopy in spinal infection surgery. They present a part of the available current literature and some cases of their own to enforce their arguments.

 

I would like to address some points:

 

suggesting that the only limit to endoscopy’s application might be our imagination.

That is an overstatement. I can list many pathologies where endoscopy would be ineffective or contraindicated. So please re-phrase or remove the statement.

 

You describe your endoscopic technique but I would like to know how many levels can you reach from a single hole, what about the level L5/S1 where the pelvis is on the way etc.

 

You should report the number of patients included in your review, all the patients in the reviewed articles together.

 

The pathogens are different in west countries and different in the developing countries where mycobacterium tuberculosis leads. You should check your literature again and discuss the issue. Your 3.2 paragraph points to a developed country.

 

The way you describe the results of the reviewed articles and the design of your study is strongly biased. Of course, if you search articles about endoscopy you will find only positive things about it but there are many disadvantages as well that you should refer to, in order to keep a balance. Furthermore, you write “suggesting that endoscopic surgery 142

is a viable and potentially superior alternative for the treatment of spondylodiscitis in 143

appropriate cases.” So yes, endoscopy can be superior in some cases but also inferior in some other. Be more consinstent, clear and unbiased please.

 

combination of MRI and fluoroscopy -> maybe add a little more detail about it. MRI with Gadolinium? T1, T2 or STIR is the most appropriate in your opinion? Describe your standard use of fluoroscopy.

 

You pretty much describe in 3.6 the endoscopic procedures as risk-free. They are not and you should refer to the most common complications of it.

 

How do you close the dura in case of injury? Can you sew it or just press some tachosil against it? What about excessive intraoperative bleeding in oncologic patients or those with anticoagulation in therapy? Is the irrigation with saline enough?

 

I like your first case, high BMI and L5/S1, a challenging case. Do you always use the interlaminar approach or just in this combination of L5/S1 (where the lateral approach is difficult) and the high BMI (where the depth would be problematic?) Why fusion however? And how do you comment the sterile cultures? Do you think the cultures of an open surgery would return sterile as well?

You talk about a CRP of 20. 20 what? mg/L?

Was the MRI with contrasting agent after the suspicion of the consultant neurosurgeon or a CT scan with contrasting agent done?

 

Was your second case operated microscopically the first 3 times?

persistent stenosis at the operated level, likely due to postoperative and inflammatory changes -> what do you mean with that? Did the first surgery remove the stenosis or not? From the pictures you provide I think not, the surgeon went through the spinal joint and did not remove the stenosis which was the leading pathology in this patient, as far as I can understand from the pictures. Please provide axial and sagital MRI pictures before surgery.

 

In case 3 comes the next big iatrogenic failure. A fracture with compression of the spinal cord has to be decompressed and then stabilized. I cannot understand how a different decision was met. Again, the very minimal invasive technique used brought sterile cultures (thrice).

 

Please provide pre- and postoperative pictures for all cases. I really appreciate the honesty of the authors, it is very noble of them to describe the cases as they really were but I am having ethical concerns with the cases, they were all badly treated and, in my opinion, bad examples to prove the endoscopic superiority.

 

You refer to stabilization of infected segments as a standard. I do not agree and it is not completely supported from the literature. There are articles for and against so it is not a widely accepted strategy. Debridement, cultures and decompression when needed but instrumentation only when needed.

 

You spend the discussion adoring endoscopy without direct comparison to open surgery. That makes your argumentation very poor. It is better than doing nothing but if you want to make a point, you should review articles that compare open surgery to endoscopic. Same thing with your cases, you celebrate good results after poor surgeries. I do not doubt your good work and results but it would be appropriate to compare them to good surgeries.

But on the other hand, if the surgery was done properly, there is no need for endoscopic procedure afterwards.

 

Your conclusion is perfect and confirms what I am writing above. Please base your discussion on it and re-write it. I agree with you, endoscopy is a valuable method for many cases but not for all or even most. Be more humble with the presentation of the method and its advantages and present the disadvantages as well.

 

I am not sure that your cases should be published. If I were one of those patients, I would have sued the doctors, no offense.  

Author Response

Response in PDF file

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript is a case series study with a systematic review to provide a basis for whether endoscopic surges can be presented as a new treatment in spinal infection management. First, congratulations on completing your successful treatment. I'll give you some corrections.

1. The scope of spinal discitis and pyogenic spondylitis is not clear in the definition of spinal infection. I agree that various endoscopic treatments, such as epidural abscesses and facet joint abscesses, can show certain advantages. However, I questioned whether it is effective even when the discitis observed on MRI is irrigated endoscopically only; the contents are mixed to see if it has been treated well.

 

2. The IRB consent was clearly exempted from the case series of retrospective studies, but personal information should not be revealed during the consent process. The content of case number 3 about Ukraine patient with HIV is entirely unnecessary. Please delete it. If not, please add IRB. 

 

3. Did you stop using antibiotics after surgery? How can a shorter hospital day be done if additional antibiotics are used? It is possible if you stopped using antibiotics after surgery, but there is not enough information on how to freeze normally. Please reinforce this.

Author Response

reply in PDF file

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The authors did a good job with this study, in particular adhering to the PRISMA statement. That said, there are several formatting errors. Please see the attached PDF.

Comments for author File: Comments.pdf

Author Response

reply in PDF file

Author Response File: Author Response.pdf