Direct Visualization of Cervical Interlaminar Epidural Injections Using Sonography

Round 1

Reviewer 1 Report

Thank you for the opportunity of reviewing the paper: “Ultrasound-Guided Cervical Epidural Injection”. This manuscript is a paper with an idea to demonstrate the use of ultrasound-guided 11 cervical interlaminar epidural injections in nine cases and propose the use of sonography, rather 12 than conventional methods, for easier and safer cervical epidural injections. Although the idea is relevant, the manuscript needs to be shown higher depth of methodology and discussion

I would recommend to the authors more consistent statistical data for detailing his work.

1. Methodology needs to be more in-depth explanation.

2. The whole discussion should be much better argued.

3. The title should be reconsider.

4. A scale bar for the figure 3, 4, 5 and 6 must be added.

Author Response

1. Methodology needs to be more in-depth explanation.

Thank you for your helpful comment. As per your suggestions, we have included a more in-depth methodology description and added a new figure. We have also deleted the figure showing the infant sonogram to avoid confusion. (Lines 61-70 and 84-97)

2. The whole discussion should be much better argued.

We appreciate your comment. To address this issue, we have included a reference to support our paper, which is the first to describe US guided CEDI (lines 337 to 348). We have focused our Discussion on the importance of visualization of CEDI procedure with regards to safety.

3. The title should be reconsider.

We changed the title to “Direct Visualization of Cervical Interlaminar Epidural Injection using Sonography” from “US guided Cervical epidural injection.”

Line 2-3

4. A scale bar for the figure 3, 4, 5 and 6 must be added.

Thank you for the valuable suggestion. We have added a scale bar for the figures.

Reviewer 2 Report

This manuscript is a case report about ultrasound-guided cervical epidural injection. As per the Instructions for Authors of the Tomography journal (https://www.mdpi.com/journal/tomography/instructions#:~:text=Tomography%20has%20no%20restrictions%20on,the%20results%20can%20be%20reproduced.), "Case reports present detailed information on the symptoms, signs, diagnosis, treatment (including all types of interventions), and outcomes of an individual patient. Case reports usually describe new or uncommon conditions that serve to enhance medical care or highlight diagnostic approaches." For the last paragraph of the Introduction section, the authors claimed that “the technique for ultrasound (US)-guided cervical interlaminar epidural steroid injection (ESI) has not been reported, and no case series has described the safety of this technique in cervical lesions. Herein, we report cases of US-guided CEDI without fluoroscopy.” However, the ultrasound-guided cervical interlaminar epidural steroid injection technique has been well explored. Literature reviews on this technique have been published elsewhere, e.g. Moreno, B.; Barbosa, J. Ultrasound-guided procedures in the cervical spine. Cureus. 2021, 13, e20361. doi: 10.7759/cureus.20361. Hence, this paper should be rejected outright as it has little value to readers and contribution to the existing knowledge, and cannot meet the Tomography journal’s case report requirements.

Author Response

Reviewer 2

Thank you for your comment.

We read the literature suggested by you. The reviews on this technique have been published elsewhere, e.g. Moreno, B. and Barbosa, J. Ultrasound-guided procedures in the cervical spine. Cureus. 2021, 13, e20361. doi: 10.7759/cureus.20361.

However, Moreno, B. and Barbosa, J. clearly mentioned that epidural procedure is impossible because of depth and the bony surface interfaces. Moreno, B. and Barbosa, J. mentioned nothing about cervical epidural injection.

The below text has been taken verbatim from the paper:

Abstract: This paper aims to show the advantages of ultrasound in facilitating the performance of cervical spine procedures, including facet joint injections, medial branch blocks, and selective nerve root blocks…

Introduction: Despite these advantages, US has some limitations in neuraxial (epidural or intrathecal) procedures as it has a limited resolution at deep levels and near bony surfaces that affect image quality, not been possible to visualize the real-time propagation of the injectable in the epidural or intrathecal space.

However, we found a study on ultrasound-guided cervical transforaminal epidural steroid injections (Zhang X, Shi H, Zhou J et al. The effectiveness of ultrasound-guided cervical transforaminal epidural steroid injections in cervical radiculopathy: a prospective pilot study. J Pain Res. 2018 Dec 31; 12:171-177.).

 We have revised the discussion as follows.

1. For cervical epidural injection, Zhang X et al. reported transforaminal epidural steroid injections.

. However, they did not visualize the spinal cord and its nutrient vessels and the radicular artery during the procedure. Serious complications such as spinal cord injury caused by direct spinal cord injury or indirect injury to the nutrient vessels were reported for transforaminal epidural steroid injections [1-3]. We visualized the spinal cord and surrounding vessels during interlaminar epidural injection using the SMI method. To the best of our knowledge, our study is the first to achieve direct visualization of not only the needle entry route but also the spinal cord and surrounding vessels during the CEDI procedure (lines 335-344).

Round 2

Reviewer 1 Report

An interesting work which deserves publication.

Author Response

For proofreading, we will again ask Editage, an English editing company, to proofread the document.

Reviewer 2 Report

Thank you for your response. My major concern has been addressed appropriately. However, manuscript editing is necessary prior to publication because grammatical errors are noted throughout the paper. Also, please remove the Microsoft Word spell check markers from Figure 1.

Author Response

We thank for your thoughtful suggestions. 

For proofreading, we will again ask Editage, an English editing company, to proofread the document.

We removed the Microsoft Word spell check markers from Figure 1.