Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Some points need to be revised. Look at these:

Lines 129-131: "This study introduces a structured Surgical Trauma Gradient model that moves beyond traditional binary... outcome framework" What is the purpose of this manuscirpt? State this better. What are the primary and secondary objectives?
Lines 378-384: "Sensitivity analyses separating exposure (minimally invasive vs. open) and biomechanical strategy (decompression vs. fusion) confirmed... " What do the authors mean? Could the authors add more data?
Lines 454-456: "Although residual confounding cannot be excluded, the persistence of... surgical burden contributes independently to outcome variability" Explain this part more.
Lines385-393: "3.7. Summary of Key Findings" This section, rather than being schematic and summarized, seems misleading. Revised this section, adding additional information, including the data in Table 4.
Lines 565-580. The conclusion doesn't seem to provide a precise summary of what was said before and at times it seems to be completely unrelated. Improve this part.

Author Response

Response to Reviewer

We sincerely thank the Reviewer for the careful evaluation of our manuscript and for the constructive and insightful comments. We have revised the manuscript extensively to improve clarity, methodological transparency, and consistency between sections. All comments have been addressed point by point as detailed below.

Comment 1

Lines 129–131:
"This study introduces a structured Surgical Trauma Gradient model..." What is the purpose of this manuscript? State this better. What are the primary and secondary objectives?

Response

We thank the Reviewer for this important comment. We agree that the objective of the manuscript required clearer and more explicit formulation.

Revision made

We revised the end of the Introduction to clearly define the study aims and removed redundant conceptual phrasing.

The revised text now reads:

“The primary objective of this study was to determine whether postoperative outcomes after spine surgery follow a graded relationship across a structured 2×2 Surgical Trauma Gradient integrating exposure-related invasiveness and biomechanical strategy.
Secondary objectives were to evaluate whether Type-D personality independently predicts postoperative outcomes and whether psychosocial vulnerability modifies the association between surgical burden and postoperative recovery.”

Comment 2

Lines 378–384:
"Sensitivity analyses... confirmed..." What do the authors mean? Could the authors add more data?

Response

We appreciate this important suggestion and agree that the previous description was too brief and insufficiently transparent.

Revision made

We have substantially expanded the sensitivity analyses and now provide both detailed numerical results and graphical representation:

Supplementary Table S1 now reports:

separate effects of exposure (minimally invasive vs. open)
separate effects of biomechanical strategy (decompression vs. fusion)
models excluding prior spine surgery
stratified analyses by pain duration

Figure S1 provides a comprehensive visualization of:

independent effects (forest plot)
robustness analyses across model specifications
interaction patterns

The Results section has been revised accordingly:

“Sensitivity analyses were performed by modeling exposure (minimally invasive vs. open) and biomechanical strategy (decompression vs. fusion) as separate predictors. Both dimensions remained independently associated with postoperative pain and disability, supporting the conceptual validity of the 2×2 framework. Exclusion of patients with prior spine surgery and stratification by pain duration quartiles did not materially alter the direction or magnitude of the main findings. Detailed regression coefficients and stratified estimates are provided in Supplementary Table S1 and S2, and graphical visualization is shown in Supplementary Figure S1.”

These additions demonstrate the robustness and internal consistency of the Surgical Trauma Gradient framework.

Comment 3

Lines 454–456:
"Although residual confounding cannot be excluded..." Explain this part more.

Response

We thank the Reviewer for highlighting this point. We agree that the original statement was too concise and required clarification.

Revision made

We expanded this section in the Discussion to explicitly address the role of potential confounding by surgical indication and disease severity:

“Although residual confounding related to surgical indication and disease severity cannot be fully excluded in an observational design, the persistence of the graded association after multivariable adjustment and across longitudinal analyses suggests that surgical burden contributes independently to outcome variability. In other words, the observed gradient is unlikely to be explained solely by baseline case complexity.”

This clarification improves interpretability and appropriately frames the observational nature of the study.

Comment 4

Lines 385–393:
"Summary of Key Findings seems misleading..."

Response

We appreciate this important comment and agree that the previous version was overly schematic and insufficiently data-driven.

Revision made

We completely revised Section 3.7 to provide a clear, quantitative, and integrated summary of findings, explicitly incorporating data from Tables 2–4:

“Across all outcome domains, a consistent gradient was observed with increasing surgical burden. At 12 months, residual pain increased from 2.12 in minimally invasive decompression to 4.13 in open fusion, while disability increased from 12.36 to 29.53 and satisfaction decreased from 4.43 to 3.17.

In multivariable models, InvasivenessScore independently predicted pain (β = 0.69; p < 0.001), disability (β = 6.20; p < 0.001), lower satisfaction (β = −0.38; p < 0.001), and complication risk (OR = 1.64; p = 0.01).

Type-D personality independently predicted worse pain (β = 0.41; p = 0.008) and significantly amplified the effect of surgical burden on postoperative pain (interaction β = 0.22; p = 0.012).

Higher-burden procedures were additionally associated with slower recovery trajectories, supporting a dose–response relationship between surgical invasiveness and postoperative outcome.”

This revised section now provides a concise but fully data-supported synthesis of the main findings.

Comment 5

Lines 565–580:
"The conclusion doesn't seem precise..."

Response

We thank the Reviewer for this valuable feedback and agree that the previous conclusion required better alignment with the presented results.

Revision made

We completely rewrote the Conclusion to ensure consistency, precision, and clinical relevance:

“Postoperative outcomes after spine surgery follow a consistent gradient of surgical burden, reflecting the combined effects of exposure-related tissue injury and biomechanical intervention. Increasing surgical burden was independently associated with higher residual pain, greater functional disability, lower patient satisfaction, and increased complication risk.
Type-D personality emerged as an independent psychosocial risk factor and significantly modified the association between surgical burden and postoperative pain.
The proposed 2×2 Surgical Trauma Gradient model provides a clinically applicable framework that may support surgical decision-making, preoperative risk stratification, patient counseling, and targeted postoperative follow-up.”

This revision ensures that the conclusion directly reflects the study findings and avoids overinterpretation.

Final Statement

We believe that these revisions have substantially improved the clarity, transparency, and scientific rigor of the manuscript. In particular, the addition of supplementary analyses (Table S1, Table S2, Figure S1) and the restructuring of key sections have strengthened both methodological robustness and clinical interpretability.

We thank the Reviewer again for the constructive feedback, which has significantly improved the quality of our work.

Reviewer 2 Report

Comments and Suggestions for Authors

Final recommendation - Major Revisions

This manuscript is recommended for Major Revision. While the study addresses a clinically relevant question with a novel conceptual framework and sound analytical methodology, revisions are required to reduce narrative redundancy, clarify key methodological decisions, strengthen the operationalisation of clinical implications, and ensure full compliance with reporting and formatting standards.

More detailed comments:

Review report – round 1

Surgical Trauma Gradient as an Independent Predictor of Post-operative Pain, Functional Recovery, and Complication Risk After Spine Surgery: A 2×2 Invasiveness Model with Psychosocial Interaction

Brief summary:

This prospective cohort study (n = 200) introduces a structured 2×2 Surgical Trauma Gradient model integrating two independent dimensions of surgical burden — exposure-related invasiveness (minimally invasive vs. open) and biomechanical strategy (decompression vs. fusion) — to evaluate postoperative outcomes following elective spine surgery. The study additionally examines the modifying role of Type-D personality on postoperative pain, functional disability, patient satisfaction, and complication risk at 12-month follow-up.

Comments on the overall concept:

Article

This manuscript presents a timely and clinically meaningful contribution to the field of spine surgery outcomes research. The proposed Surgical Trauma Gradient framework is conceptually original, moving beyond conventional binary surgical classifications to model operative burden as a graded and multidimensional construct. The integration of psychosocial vulnerability — specifically Type-D personality — into a structured surgical outcome model is innovative and adds significant value to the existing literature.

Specific Comments

Title (Lines 2–5)

The title is clear, informative, and well-aligned with the study content. However, it could be slightly shortened to improve readability and fluency without losing its essential meaning. Suggested alternative: "Surgical Trauma Gradient as a Predictor of Postoperative Outcomes in Spine Surgery: A 2×2 Model Integrating Psychosocial Factors."

Abstrat (Lines 13–38)

The abstract is well-structured and coherently presents the study objectives, methods, and conclusions. However, several study-specific acronyms (MIS-D, O-D, MIS-F, O-F, VAS, ODI, PSI) are introduced. It is recommended that these abbreviations be removed from the abstract entirely and introduced only in the main text, at the point of first use, following the standard convention of spelling out the full term before the abbreviation in parentheses and consistently using the acronym thereafter.

Keywords (Lines 39–40)

The selected keywords are appropriate and relevant to the study. However, it is suggested that "Type-D personality" be added as an explicit keyword, given its central role in the study's hypothesis and findings. This term is indexed in MeSH (https://meshb.nlm.nih.gov/record/ui?ui=D064415) and its inclusion would improve discoverability of the article in systematic searches.

Note on Introduction (Lines 42–132)

The introduction is well-constructed, clearly establishing the clinical relevance of low back pain, the role of Type-D personality, and the need for more precise models of surgical burden characterisation. The rationale for the Surgical Trauma Gradient is sufficiently detailed and convincingly supports the 2×2 framework.

Materials and methods

Strengths

The methods section demonstrates an excellent level of detail. The inclusion of advanced analytical strategies — multivariable regression, logistic regression, interaction analysis, and mixed-effects models — is appropriate and well-justified. Outcome measures and covariables are clearly defined and grounded in validated instruments.

Concerns and Suggestions

Exclusion of intraoperative variables (Lines 176–178)

Variables such as operative time and estimated blood loss are reported to have been collected but excluded from the gradient model. The authors should clarify whether this decision was driven by concerns over multicollinearity with the invasiveness score or by a deliberate conceptual choice to maintain model parsimony. Either justification is acceptable, but it should be explicitly stated.

Classification of surgical edge cases (Lines 175–189)

The surgical classification criteria do not address several clinically relevant scenarios. It would be useful to clarify whether intraoperative conversions from minimally invasive to open approaches occurred, how intraoperative complications (e.g., haemorrhage, dural tears, surgical site infections) were handled, and whether any such cases led to reclassification within the 2×2 model.

Exclusion criteria (Lines 162–171)

The exclusion criteria list is comprehensive but lengthy. For improved readability, it is suggested that criteria be grouped into thematic categories — for example, neurological, metabolic, and psychiatric — rather than presented as a single undifferentiated list.

Psychosocial assessment (Lines 192–199)

The DS14 is a well-validated instrument. If available, the authors should report the internal consistency (Cronbach's α) of the scale as used in the present German-speaking sample, to further support its psychometric adequacy in this specific population.

Normality testing (Line 230)

Given the sample size of 200 participants, the choice of the Shapiro-Wilk test warrants consideration. This test is generally recommended for smaller samples, whereas the Kolmogorov-Smirnov test may be methodologically more appropriate at this sample size. The authors are encouraged to justify their choice or consider revising accordingly.

Reporting guideline

The authors do not indicate adherence to any established reporting guideline for observational research. It is recommended that they confirm whether the STROBE checklist for cohort studies was followed, as this would strengthen methodological transparency and is consistent with best practice for longitudinal observational research.

Results

Strengths

The results are presented clearly and systematically. Tables are well-organised and easy to interpret, and the gradient structure is consistently applied across all outcome domains. Multivariable models are appropriately reported with effect estimates, confidence intervals, and p-values. The figures effectively complement the narrative and provide intuitive visual support for the key findings, particularly the monotonic gradient pattern and the longitudinal recovery trajectories.

Suggestions for Improvement

Complication definitions (Lines 331–336)

Complication rates are reported across groups and the logistic regression results are clearly presented. However, the nature of the complications is not described. A brief breakdown of complication types would considerably strengthen the clinical interpretability of these findings and allow readers to assess whether complication profiles differ qualitatively across the gradient.

Interaction analysis (Lines 358–367)

The description of the Type-D × Invasiveness interaction is conceptually clear and the statistical reporting is adequate. However, the clinical meaning of this interaction would be strengthened by reporting the predicted absolute difference in VAS scores between Type-D and non-Type-D patients. This would allow readers to appreciate the practical magnitude of the effect modification beyond the regression coefficient alone.

Discussion

The discussion is comprehensive, scientifically rigorous, and commendably multidisciplinary in scope. The integration of biomechanical, inflammatory, and autonomic mechanisms provides a convincing and biologically grounded explanatory framework for the observed gradient. The acknowledgement of limitations is balanced and intellectually honest. The connection to prior work by the same group, as well as to the broader literature on Type-D personality and chronic pain, is well-handled and appropriately contextualised.

Concerns and Suggestions

Repetition of key concepts

The discussion would benefit from editorial consolidation in several places. Certain mechanistic themes — notably the relationship between fusion procedures and greater tissue disruption, and the role of the cholinergic anti-inflammatory pathway in the context of Type-D personality — are addressed across multiple paragraphs with considerable conceptual overlap. It is suggested that the authors reorganise these passages into single, more focused sections, one addressing the inflammatory-nociceptive axis and one addressing the autonomic-vagal axis, rather than distributing related ideas across different parts of the discussion.

Practical implications

The clinical implications are acknowledged but could be made more operationally specific across three dimensions: preoperative screening, whereby the DS14 could be routinely integrated into standard spine surgery pre-assessment protocols, with a positive screen prompting psychological support or prehabilitation prior to high-burden procedures; perioperative pathway adaptation, with Type-D positive patients scheduled for high-burden surgery flagged for enhanced postoperative monitoring and structured multidisciplinary follow-up; and surgical decision-making, where psychosocial risk could serve as an additional factor favouring lower-burden approaches when both options are clinically equivalent.

Generalisability

The discussion does not explicitly address the generalisability of the findings beyond the single tertiary academic centre in which the study was conducted. Given that case-mix, surgical technique standardisation, and perioperative protocols may differ substantially across institutions, a brief comment on the external validity of the proposed gradient model would be appropriate.

Conclusion

The conclusion is well-aligned with the reported findings and appropriately summarises the main contributions of the study. The emphasis on the interaction between surgical burden and psychosocial vulnerability is well-placed and consistent with the manuscript's central thesis.

However, the conclusion would benefit from a more explicit articulation of the model's immediate clinical applicability. The 2×2 Surgical Trauma Gradient framework is, in principle, ready for implementation in current clinical practice without requiring additional resources or technology. Specifically, the authors are encouraged to add two to three sentences highlighting that the proposed classification can already support: (i) surgical planning and decision-making regarding minimally invasive versus open approaches when anatomical conditions permit; (ii) preoperative risk stratification, particularly through routine psychosocial screening with the DS14 to identify Type-D patients at elevated risk of persistent pain and delayed recovery; (iii) patient counselling and expectation management, allowing clinicians to communicate more accurately the likely recovery trajectory based on both surgical and psychological risk profile; and (iv) targeted postoperative follow-up, with more intensive monitoring and multidisciplinary support allocated to patients in higher-burden surgical groups, particularly those with Type-D personality.

Furthermore, it is suggested that the conclusion briefly acknowledges the next necessary step in the translational pathway — namely, prospective studies incorporating biological mediators such as inflammatory biomarkers and autonomic parameters (e.g., heart rate variability), which would allow mechanistic validation of the gradient model and inform future interventional trials targeting perioperative neuromodulation or psychosocial prehabilitation.

References

The reference list is current, relevant, and well-selected. Coverage of both the psychosocial and surgical dimensions is appropriate, and the inclusion of recent systematic reviews and meta-analyses strengthens the evidence base.

It is recommended that the authors verify full consistency with MDPI formatting guidelines, specifically about journal name italicisation, placement of commas and full stops relative to DOI links, and uniform capitalisation of article titles. A small number of references appear to follow a slightly different citation style (e.g., reference 34, line 678, and reference 35, line 680), which use author-date format with ampersands rather than the numbered Vancouver-style format applied throughout the remainder of the list. These should be standardised accordingly.

English

The manuscript is written in globally very good English. The prose is clear, appropriately formal, and scientifically precise throughout. The following minor observation is offered for consideration:

Line 471: "inflammatory mechanisms likely represents" contains a subject-verb agreement error and should read "inflammatory mechanisms likely represent."

Final recommendation - Major Revisions

Author Response

Response to Reviewer 2

We sincerely thank the Reviewer for the thorough, constructive, and highly insightful evaluation of our manuscript. We greatly appreciate the recognition of the conceptual novelty and clinical relevance of our work. We have carefully revised the manuscript to address all comments and to improve clarity, methodological transparency, and clinical applicability.

All points are addressed below.

Comment 1 – Title

Suggestion to shorten the title

Response

We appreciate this suggestion. However, we elected to retain the original title, as it explicitly reflects the two core innovations of the study: the structured Surgical Trauma Gradient and the integration of psychosocial interaction. We believe this level of specificity improves indexing and accurately represents the scope of the work.

Comment 2 – Abstract (Abbreviations)

Response

We fully agree.

Revision made

All study-specific abbreviations (MIS-D, O-D, MIS-F, O-F, VAS, ODI, PSI) have been removed from the abstract. Outcomes and surgical groups are now described in full terms to improve readability and comply with reporting standards.

Comment 3 – Keywords

Response

We thank the Reviewer for this excellent suggestion.

Revision made

The keyword “Type-D personality” has been added to improve discoverability and indexing.

Comment 4 – Exclusion of intraoperative variables

Response

We agree that this required clarification.

Revision made

The Methods section now explicitly states:

“Operative characteristics such as operative time, estimated blood loss, and number of operated levels were recorded but deliberately not incorporated into the gradient model in order to preserve conceptual parsimony and maintain a clinically interpretable framework.”

This reflects a conceptual modeling decision, rather than a statistical limitation.

Comment 5 – Surgical classification edge cases

Response

We appreciate this important point.

Revision made

We clarified classification rules:

“In cases of intraoperative conversion from minimally invasive to open surgery, classification was assigned according to the final surgical technique. Intraoperative adverse events were recorded as complications but did not alter subgroup classification.”

Comment 6 – Exclusion criteria readability

Response

We agree.

Revision made

Exclusion criteria were reorganized into thematic categories (neurological, metabolic, psychiatric), improving readability and structure.

Comment 7 – DS14 internal consistency

Response

We appreciate this suggestion.

Revision made

Rather than reporting sample-specific values, we now reference the validated German DS14 version:

“In the validated German version, internal consistency has been reported as Cronbach’s α = 0.87 for negative affectivity and α = 0.86 for social inhibition.”

This approach avoids sample-specific bias and aligns with psychometric best practice.

Comment 8 – Normality testing

Response

We thank the Reviewer for this methodological consideration.

Revision made

We retained the Shapiro–Wilk test but clarified that it was complemented by visual inspection:

“Normality was assessed using Shapiro–Wilk testing in combination with visual inspection of histograms and Q–Q plots.”

This reflects current best practice in applied clinical statistics.

Comment 9 – Reporting guideline (STROBE)

Response

We agree.

Revision made

We added:

“This study was conducted and reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cohort studies.”

Comment 10 – Complication definitions

Response

We agree that this improves clinical interpretability.

Revision made

The Results section now includes:

“Reported complications included wound-related complications, postoperative hematoma requiring intervention, neurological symptoms, and medical adverse events.”

Comment 11 – Interaction analysis (clinical interpretation)

Response

We fully agree and have substantially strengthened this section.

Revision made

We added model-derived predicted values:

Supplementary Table S2 (numerical margins)
Figure S1 (visual interaction)

The Results section now states:

“Predicted marginal effects indicated that Type-D patients exhibited approximately 0.6–0.8 higher VAS points at the highest invasiveness level compared with non-Type-D patients, illustrating the clinical relevance of the interaction effect (Supplementary Table S2).”

Comment 12 – Discussion (repetition / structure)

Response

We appreciate this important editorial suggestion.

Revision made

The Discussion was restructured to reduce redundancy and consolidate mechanistic sections into:

Inflammatory–nociceptive axis
Autonomic–vagal regulation

This improved clarity and reduced repetition.

Comment 13 – Clinical implications

Response

We fully agree and have strengthened this section substantially.

Revision made

Clinical implications were expanded and operationalized:

DS14-based preoperative screening
risk-adapted perioperative pathways
decision-making support for minimally invasive approaches
targeted postoperative follow-up

We added:

„Routine preoperative screening using the DS14 may help identify patients at risk. In patients with Type-D personality, targeted prehabilitation strategies, including psychological support and expectation management, may be particularly beneficial. Patients undergoing high-burden procedures—especially those with psychosocial vulnerability—may benefit from structured perioperative support and enhanced follow-up.”

Comment 14 – Generalisability

Response

We agree.

Revision made

We added:

“Causal inference cannot be established due to the observational design. Unmeasured confounding related to surgical indication remains a relevant limitation. As this study was conducted in a single tertiary academic center, external validity may be influenced by institutional factors.”

Comment 15 – Conclusion (clinical applicability)

Response

We thank the Reviewer for this important suggestion.

Revision made

The Conclusion was expanded to explicitly state clinical applicability, including:

surgical planning
risk stratification using DS14
patient counselling
targeted follow-up

We added:

Comment 16 – References formatting

Response

We agree.

Revision made

All references were standardized according to MDPI/Vancouver style. Inconsistencies (including author-date formats) were corrected.

Comment 17 – Language

Response

Corrected.

Revision made

The grammatical issue has been corrected:

“mechanisms likely represent”

Final Statement

We are grateful for the Reviewer’s highly constructive and detailed feedback. The revisions have significantly improved the manuscript in terms of clarity, methodological rigor, and clinical applicability. In particular, the addition of Supplementary Tables S1–S2 and Figure S1 has strengthened transparency and interpretability.

We believe the manuscript is now substantially improved and suitable for publication.

Reviewer 3 Report

Comments and Suggestions for Authors

There is no clearly stated objective. Part of the introduction consists of a description of the methods and a partial discussion.

The study’s limitations are not clearly outlined.

In future, it would be worthwhile to assess the effectiveness of the methods used in relation to their invasiveness, based on scales of injury severity, neurological and pain scales, quality of life and the extent of functional improvement.

It would be worthwhile to include the results of the open interventions chosen by surgeons in the conclusions; a 20% complication rate is indeed high. Furthermore, consideration should be given to preparing patients psychologically for surgery, regardless of the type of intervention. It appears that this stems from a lack of information prior to the procedure, which is particularly acute in certain personality types. Therefore, these patients—and there are quite a few of them—require special care.

Author Response

Response to Reviewer 3

We sincerely thank the Reviewer for the constructive and clinically insightful comments. We appreciate the emphasis on clarity of study objectives, explicit limitations, and practical implications for patient care. The manuscript has been revised accordingly.

Comment 1 – Objective not clearly stated

“There is no clearly stated objective. Part of the introduction consists of a description of the methods and a partial discussion.”

Response

We thank the Reviewer for this important observation and agree that the objective required clearer formulation and structural separation from methodological elements.

Revision made

We revised the Introduction to remove methodological descriptions and explicitly state the study aims:

This revision improves conceptual clarity and aligns the Introduction with standard reporting structure.

Comment 2 – Limitations not clearly outlined

Response

We fully agree and appreciate this suggestion.

Revision made

The Limitations section has been substantially strengthened and now explicitly states:

This revision provides a clearer and more transparent appraisal of study limitations.

Comment 3 – Suggestion for future outcome evaluation frameworks

“In future, it would be worthwhile to assess the effectiveness… based on injury severity, neurological and pain scales…”

Response

We thank the Reviewer for this valuable perspective and agree that integration of additional clinical and biological outcome domains would further strengthen the model.

Revision made

We incorporated this suggestion into the Discussion (future directions):

“Future studies should extend the Surgical Trauma Gradient framework by incorporating objective measures of disease severity, neurological status, quality of life, and functional recovery, as well as biological markers, to further refine risk stratification and mechanistic understanding.”

Comment 4 – High complication rate in open procedures

“20% complication rate is high…”

Response

We appreciate this important clinical observation.

Revision made

We clarified this point in both Results and Discussion:

Results: added description of complication types
Discussion: contextualized findings:

“Higher complication rates observed in open fusion procedures likely reflect both increased surgical burden and underlying disease severity, although residual confounding cannot be fully excluded.”

This ensures balanced interpretation without overstatement.

Comment 5 – Psychological preparation of patients

“Patients require psychological preparation… especially certain personality types…”

Response

We strongly agree with this important clinical insight, which aligns closely with the central findings of our study.

Revision made

We significantly expanded the Clinical Implications section:

“Routine preoperative screening using the DS14 may help identify patients at risk. In patients with Type-D personality, targeted prehabilitation strategies, including psychological support and expectation management, may be particularly beneficial. Patients undergoing high-burden procedures—especially those with psychosocial vulnerability—may benefit from structured perioperative support and enhanced follow-up.”

This directly addresses the Reviewer’s suggestion and strengthens the translational relevance of the study.

Final Statement

We thank the Reviewer for the thoughtful and clinically relevant comments. The manuscript has been revised to improve clarity of objectives, strengthen the limitations section, and enhance clinical applicability—particularly regarding psychosocial screening and perioperative patient management.

We believe these revisions have significantly improved the overall quality and practical relevance of the manuscript.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Good

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have responded thoroughly and convincingly to all reviewer comments, resulting in a clearly improved and methodologically robust manuscript. The study represents a valuable and clinically relevant contribution to the field. I congratulate the authors on their excellent work and recommend the manuscript for acceptance.

Review Reports

Response to Reviewer

Comment 1

Comment 2

Comment 3

Comment 4

Comment 5

Final Statement

Response to Reviewer 2

Response to Reviewer 3