Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Repetitive Transcranial Magnetic Stimulation for Intractable Neuropathic Pain Following Post-Traumatic Lumbosacral Plexopathy: A Case Report

Introduction

• Key sentence: “To date, no prior reports have described the use of rTMS…”
• Suggested enhancement: add a sentence emphasizing the clinical significance, e.g., the lack of therapeutic options for young patients and the good safety profile of rTMS.
• It would be useful to mention the safety of rTMS in adolescents either in the introduction or in the Case Report section.

Case Report

• Explain minor inconsistencies in pain assessments.
• Highlight the safety of rTMS in a minor patient.
• Briefly comment on the clinical significance of changes in SF-MPQ and NPSI scores.
• Mention possible reasons for the temporary worsening of BDI.
• It is recommended to separate the Case Report section from Results for clarity.

Results

• The discussion does not directly refer to the patient’s outcomes (NRS, BDI, EQ-5D-5L).
• The lack of a control group and randomization should be stated as limitations of case reports.

Discussion

• Consider dividing into thematic paragraphs (epidemiology, mechanisms, safety, depression/QoL, limitations).
• Refer directly to the patient’s results.
• Simplify the description of mechanisms to make it more accessible for clinical readers.
• Add references regarding the efficacy and safety of rTMS in young patients and comparisons with other studies.

 

Comments on the Quality of English Language

Language and Style

• There are typographical errors in the text (e.g., “trascranial sitmulation” → “transcranial stimulation”).
• Full English proofreading is recommended, and terminology should be standardized (HF-rTMS, NRS, SF-MPQ).

Author Response

Response to Reviewer 1

We sincerely thank the Reviewer for the thoughtful and constructive comments.
We have carefully revised the manuscript in accordance with the suggestions.
All modifications have been incorporated into the revised manuscript and marked in highlight.
Below, we provide a point-by-point response.

Comment 1 – Introduction

Reviewer Comment 1:
Key sentence: “To date, no prior reports have described the use of rTMS…”
Suggested enhancement: add a sentence emphasizing the clinical significance, e.g., the lack of therapeutic options for young patients and the good safety profile of rTMS. It would be useful to mention the safety of rTMS in adolescents either in the introduction or in the Case Report section.

Response 1:
We appreciate this important suggestion. We have expanded the Introduction to emphasize the clinical significance of identifying alternative treatment options in young patients with severe traumatic neuropathic pain. Specifically, we added a statement highlighting the limited long-term pharmacologic options in adolescents and the favorable safety profile of rTMS. In addition, we explicitly addressed the safety of rTMS in adolescents both in the Introduction and in the Case Report section, where we described adherence to established safety guidelines and the absence of adverse events in this minor patient (line 72-83).

 

Comment 2 – Case Report

Reviewer Comment 2:
Explain minor inconsistencies in pain assessments.
Highlight the safety of rTMS in a minor patient.
Briefly comment on the clinical significance of changes in SF-MPQ and NPSI scores.
Mention possible reasons for the temporary worsening of BDI.
It is recommended to separate the Case Report section from Results for clarity.

Response 2:
We thank the Reviewer for these constructive suggestions. We added a clarifying paragraph explaining that differences between NRS, SF-MPQ, and NPSI results likely reflect the distinct constructs measured by each tool (intensity vs. qualitative descriptors of neuropathic pain). We explicitly emphasized the safety monitoring procedures and absence of adverse effects in this minor patient (line 105-109).

We included comments regarding the clinical relevance of changes in SF-MPQ, NPSI, and EQ-5D-5L scores, noting that the magnitude of QoL improvement may be considered clinically meaningful (line 128-132, 140-143, and 170-172).

We provided a brief explanation for the temporary worsening of BDI scores, suggesting psychological stress, expectation effects, or fluctuating pain perception rather than a direct adverse effect of rTMS (157-160).

As recommended, we separated the “Case Report” and “Results” sections to improve clarity and logical structure.

 

Comment 3 – Results

Reviewer Comment 3:
The discussion does not directly refer to the patient’s outcomes (NRS, BDI, EQ-5D-5L).
The lack of a control group and randomization should be stated as limitations of case reports.

Response 3:
We agree with this comment.

We revised the Discussion to explicitly reference the patient’s quantitative outcomes, including NRS reduction (6 to 2), long-term NPSI improvement (53 to 40), BDI changes (62 to 31 at follow-up), and clinically meaningful improvement in EQ-5D-5L index (line 224-229).

We strengthened the Limitations section to clearly state that, as a single case report, the study lacks a control group, randomization, and blinding, and therefore causal inference is limited and placebo effects cannot be excluded (line 249-251).  

 

Comment 4 – Discussion

Reviewer Comment 4:
Consider dividing into thematic paragraphs (epidemiology, mechanisms, safety, depression/QoL, limitations).
Refer directly to the patient’s results.
Simplify the description of mechanisms to make it more accessible for clinical readers.
Add references regarding the efficacy and safety of rTMS in young patients and comparisons with other studies.

Response 4:
We appreciate these valuable recommendations.

The Discussion has been reorganized into thematic subsections: Epidemiology and clinical context, Mechanisms of rTMS, Safety considerations in adolescents, and limitations.

We directly referenced the patient’s outcome measures to strengthen the connection between the discussion and clinical data (line 224-229).

The description of neurophysiological mechanisms has been simplified to improve accessibility for clinical readers, while retaining scientific accuracy (line 218-220).

We added supporting references regarding the safety and clinical application of rTMS in adolescent populations and expanded comparisons with prior neuropathic pain studies (line 235-238).

 

We sincerely thank the reviewer for this helpful comment. The typographical errors in the manuscript (e.g., “trascranial sitmulation”) have been corrected. Furthermore, the manuscript has undergone thorough English proofreading to improve clarity and readability. The terminology and abbreviations (e.g., HF-rTMS, NRS, and SF-MPQ) have also been standardized throughout the manuscript to ensure consistency.

 

 

We sincerely thank the Reviewer for the insightful comments, which have significantly strengthened the clarity, structure, and clinical relevance of our manuscript. We believe that the revisions have improved the scientific rigor and readability of the paper.

 

We respectfully submit the revised manuscript for reconsideration.

Jae-Hyung Kim, MD, PhD
Corresponding Author

 

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Author!

This manuscript is a well-written and clinically relevant case report demonstrating the potential efficacy of high-frequency rTMS in an adolescent patient with severe post-traumatic lumbosacral plexopathy.

In addition to the obvious strengths, I would like to draw attention to several points in your manuscript.
1. References 4, 6, 11, 13, and 14 need to be updated—these sources are over 10 years old and may not be relevant.
2. Inconsistencies and potentially irrelevant dosages have been identified in the description of pharmacotherapy.
a) Paracetamol 487.5 mg—where does the 0.5 mg in the dosage come from? Is this an individual calculation?
b) Tramadol 56.25 mg - same question about 0.25 mg
Overall, this appears to be a statistical average, but for clinical practice, it is still advisable to report actual doses.
3. NRS data inconsistency: 8 in the abstract, 6 on lines 107-108, and 8 on line 94. The data needs to be verified and presented correctly.
4. You need to check the accuracy of the data summaries in Table 1.

 

Author Response

Dear Reviewer 2 ,

We sincerely thank the reviewer for the careful evaluation of our manuscript and for the constructive comments that helped us improve the clarity and accuracy of the manuscript. We have carefully revised the manuscript according to the reviewer’s suggestions. All modifications have been incorporated into the revised manuscript, and the newly added or modified text is indicated in italic font.

Below we provide a point-by-point response to each comment.

 

Comment 1

References 4, 6, 11, 13, and 14 need to be updated—these sources are over 10 years old and may not be relevant.

Response 1:

We appreciate the reviewer’s suggestion. We reviewed the reference list and updated the cited literatures to include more recent studies and reviews related to contents (line 299, 303, 311-312, 320-322).

 

Comment 2

Inconsistencies and potentially irrelevant dosages have been identified in the description of pharmacotherapy.
a) Paracetamol 487.5 mg—where does the 0.5 mg come from?
b) Tramadol 56.25 mg—same issue.
These values appear to represent statistical averages rather than actual clinical doses.

Response

We thank the reviewer for pointing out this issue.To improve clarity and clinical relevance, we revised the manuscript to report the actual prescribed doses used in clinical practice (line 98-99).

 

Comment 3

NRS data inconsistency: 8 in the abstract, 6 on lines 107–108, and 8 on line 94. The data needs to be verified and presented correctly.

Response 3:

We appreciate the reviewer’s careful observation. After rechecking the clinical records, we confirmed that the correct baseline pain score was NRS 8. Therefore, we revised the manuscript to consistently report NRS 8 as the baseline value throughout the Abstract, Case Report, and Results sections (line 22-23, 127).

 

Comment 4

You need to check the accuracy of the data summaries in Table 1.

Response 4

We thank the reviewer for highlighting this issue. Following this suggestion, we carefully rechecked the Neuropathic Pain Symptom Inventory (NPSI) data and corrected Table 1 to ensure internal consistency between component scores and the total scores (Table 1).

 

 

We sincerely thank the reviewer for the insightful comments and constructive suggestions, which have significantly improved the clarity and scientific accuracy of our manuscript.

Sincerely,

Jae-Hyung Kim, MD, PhD
Corresponding Author

 

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors, this manuscript offers a compelling and clinically significant case that details the application of high-frequency rTMS for refractory neuropathic pain resulting from traumatic lumbosacral plexopathy. The subject matter is appropriate for publication as a case report and highlights a clinical indication that is infrequently documented.

 

Major comments

 

1) The Introduction could be enhanced by a more explicit articulation of its novelty. The authors assert that there are no previous reports, yet this assertion should be bolstered by a more systematic comparison with existing rTMS applications in the context of peripheral neuropathic pain.

 

2) Given that this is a single-case report, the discussion should more clearly recognize the potential roles of placebo effects and spontaneous recovery as factors contributing to the observed clinical improvement.

 

3) The observed temporal increase in BDI scores immediately following treatment necessitates a more thorough interpretation and clinical rationale.

 

Minor comments

 

1) Numerous linguistic and typographical mistakes should be rectified throughout the manuscript.

 

2) The legends for Figures 1 and 2 are somewhat explanatory but could place greater emphasis on clinical significance rather than merely reiterating results.

 

3) The tables would benefit from improved formatting and consistent terminology (for instance, regarding follow-up notation).

 

4) It may be worthwhile to briefly address the limitations associated with stimulation target localization, particularly in relation to the non-neuronavigated approach.

 

Kind regards!

Comments on the Quality of English Language

Minor grammar spell check needed.

Author Response

Dear Editor and Reviewer 3,

We sincerely thank you for your careful evaluation of our manuscript and for the constructive comments that helped us improve its scientific clarity and clinical relevance. We have revised the manuscript accordingly. All changes have been incorporated into the revised text, and modified parts are indicated in italics as requested.

Below, we provide a point-by-point response to each comment.

 

Response to Reviewer

Major Comments

Reviewer comment 1: “The Introduction could be enhanced by a more explicit articulation of its novelty. The authors assert that there are no previous reports, yet this assertion should be bolstered by a more systematic comparison with existing rTMS applications in the context of peripheral neuropathic pain.”

Response 1:
We agree with the reviewer. We revised the Introduction to more clearly articulate the novelty of this report and to contextualize it within existing rTMS literature on neuropathic pain. Specifically, we added a paragraph explaining that most clinical evidence on rTMS analgesia relates to central neuropathic pain (e.g., post-stroke pain, spinal cord injury–related pain, and CRPS), whereas reports in traumatic peripheral plexopathies are extremely limited, thereby highlighting the clinical gap addressed by our case (line 72-80).

 

Reviewer comment 2: “Given that this is a single-case report, the discussion should more clearly recognize the potential roles of placebo effects and spontaneous recovery as factors contributing to the observed clinical improvement.”

Response 2: We fully agree. We revised the Discussion to explicitly acknowledge that placebo effects and spontaneous neurological recovery may have contributed to the clinical improvements observed. We emphasized that these factors limit causal inference, and therefore results must be interpreted cautiously (line 248-250).

 

Reviewer comment 3: “The observed temporal increase in BDI scores immediately following treatment necessitates a more thorough interpretation and clinical rationale.”

Response 3: We thank the reviewer for highlighting this important point. We added a clearer clinical interpretation in the Results section to explain potential reasons for transient BDI worsening (line 156-159).

 

Minor Comments

Reviewer comment 4: “Numerous linguistic and typographical mistakes should be rectified throughout the manuscript.”

Response 4:
We agree and have carefully proofread the entire manuscript. We corrected typographical errors, improved sentence structure, and refined wording for clarity and readability throughout.

 

Reviewer comment 5: “The legends for Figures 1 and 2 are somewhat explanatory but could place greater emphasis on clinical significance rather than merely reiterating results.”

Response 5:
We agree. We revised both figure legends to highlight clinical meaning and relevance (e.g., describing the NRS reduction as clinically meaningful and emphasizing sustained follow-up change). We also clarified that changes suggest an immediate and partially sustained effect. In addition, the clinical interpretation of these findings has been added to the Results section of the revised manuscript (line 128-131, 156-159).

 

Reviewer comment 6: “The tables would benefit from improved formatting and consistent terminology (for instance, regarding follow-up notation).”

Response 6:
We appreciate the reviewer’s helpful comment. The tables have been reformatted to improve clarity and consistency. In particular, the follow-up notation has been standardized, and the term “10-week follow-up” has replaced “long-term FU” throughout the manuscript, including in the text, figures, and tables.

 

Reviewer comment 7: “It may be worthwhile to briefly address the limitations associated with stimulation target localization, particularly in relation to the non-neuronavigated approach.”

Response 7:
We appreciate this valuable suggestion. We added a brief statement in the Case Report acknowledging that stimulation was performed without neuronavigation and relied on scalp landmark localization. We also added a clarifying sentence noting that while neuronavigation may improve spatial accuracy, landmark-based targeting is commonly used in routine clinical rTMS and has acceptable reliability in therapeutic protocols (line 256-262).

 

Sincerely,
Corresponding Author

Jae-Hyung Kim, MD, PhD

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for submitting the revised version of the manuscript. It is evident that a number of substantive and editorial corrections have been implemented in accordance with the suggestions, which has improved the clarity and overall structure of the manuscript.

However, some issues remain regarding the references. The format of the reference list and the in-text citations are still not fully consistent with the journal’s guidelines. Therefore, please carefully review and adjust both the bibliography and the citation style in the text to ensure full compliance with the journal requirements.

After these corrections are implemented, the manuscript may be reconsidered.

 

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors, I have no further comments. Kind regards!