Pathological Mechanisms and Additional Factors Involved in Complex Neck Traumatology

Round 1

Reviewer 1 Report

Manuscript

 ID number:  1458245

Title of paper: Pathological Mechanisms and Additional Factors Involved in 2

the Evolution of Complex Cervical Traumatology

Reviewer response

 Title & Abstract

1. Do the title and abstract cover the main aspect of the work?

The title requires reformulation because the study shows comorbidities and predisposing factors associated with trauma and not the evolution of injuries.

The abstract meets the requirements of the journal and is relevant to the content of the article, but the purpose of the study is strictly statistically related to the epidemiology of cervical trauma, but does not refer to the evolution and social integration and evolution of patients with this diagnosis.

 

2. Introduction

The introduction provides context and information relevant to the study, but the aim of the study should be clearly explained at the very end of Introduction section. The objective of the study is to establish the epidemiology, morphopathology of the studied cases of cervical trauma, but it does not refer to the evolution and social integration of these cases.

3. Material and Methods

 The design of the study should be explained, the Authors should clearly explain how the distribution of data was checked, detailing the statistical methods used. Which statistical tests were used for testing the difference and the correlations?

 Ethical approval is missing. Written informed consent, if obtained, is missing.

 

4. Results

The results are relevant for the literature, but in paragraph 162-166 the data in the text do not correlate with those in the figure.

 

5. Discussion

The findings described by the author correlate with the results, and the findings are relevant to the literature. They are correlated with the results of other studies that follow the subject of the article.

 

6. Conclusion

The conclusion could be developed more to answer research question. What are the strengths and limitations of the study?

 

7. Figures & Tables

The figures and tables are clear and legible, the author has provided the necessary figures and tables

 

8. Concerns, Competing interest, English editing

The paper does not raise any concerns Competing interest.

 No English editing.

No additional comments

 

Author Response

Response to Reviewer 1 Comments

Point 1:
The new title of the article is „Pathological Mechanisms and Additional Factors Involved in Complex Neck Traumatology”.
I corrected the aims of the study as you suggested. The objectives of the study are to establish the particularities of epidemiological, morphopathological, and pathophysiological factors involved in complex neck traumatology.
Point 2:
As indicated I corrected the final part of Introduction with a clearly explaination for the objective of the study which are to establish the particularities of epidemiological, morphopathological, and pathophysiological factors involved in complex neck traumatology.
Point 3:
The selected study is a part of the PhD study thesis, which includes other 3 studies related to complex neck traumatology.
The size of the sample (n = 384) is representative of the population of Moldova, the North-East Development Region with a population of about 3,302 million inhabitants. The sampling error was ± 5%. The study group was divided into two groups according to the clinic in which the patients were investigated: 106 patients admitted to the ENT department of "Sf. Spiridon "Emergency Clinical Hospital in Iaşi between 2012 and 2016 and 278 patients from the Institute of Forensic Medicine, Iaşi, deceased by complex cervical pathology between 2012 and 2014. The both of the institution are tertiary hospitals for that region of the country. Patient data collected for this study were kept confidential. This research study was submitted to the analysis and then to the approval by the Ethics Committees of both "Grigore T. Popa" University of Medicine and Pharmacy and the "Sf. Spiridon " Emergency Hospital, Iasi.
The information selected from the observation sheets was in the following categories: demographic data, epidemiological characteristics, lesion appearance and mechanism, cervical location corresponding to defined areas of the neck, type and extent of injured tissues, paraclinical investigations, associated pathologies or recurrences, therapeutic approach, complications and also the data obtained from the regular consultations performed at the hospital discharge.
General exclusion criteria: age under 18 years; the patient's refusal to participate, the presence of cervical trauma in the past but without pathological lesions or only superficial lesions without being accompanied by symptoms.
The data were uploaded and processed using the statistical functions in SPSS 18.0. Significance tests used: t-Student test, F test (ANOVA), Kruskall-Wallis correlation “Pearson” correlation coefficient (r), linear trend ((? = ?? + ?).
Point 4: paragraph 162-166 the data in the text, they do correlate with those in the figure.

Statistically, the determining mechanism of cervical trauma on both groups was the self-inflicted one with a percentage of 78.4%, followed by aggression in 14.8% of cases, and last but not least, the accidental mechanism in a percentage of 6.8% (Figure 1). Compared to study groups, the ANOVA test was used to highlight statistically significant percentage differences (p = 0.001): - in group 1 (n = 106), the lesion determining mechanism through aggression (39.6%) was more frequently noticed, followed by the autolytic mechanism (39.6%) and the accidental mechanism (22.6%); (Figure 2) - in group 2 (n = 289), in 93.9% of patients the autolytic mechanism was present, to the detriment of aggression (5.4%) and the accidental mechanism (0.7%) (Figure 2).
 
 
Point 5:
Point 6:
The strenghts of the study consists in amount of cases that we studied, all the severe cases from all over county of Moldova were referred here, being a tertiary hospital unit. Unfortunately,  the limitation of the study consists in the fact that de patient with neurosurgical or vascular predominant lesions, we didn’t had the opportunity to include them in study due to the fact that in our city the neurosugical unit is in a separate hospital, we include the ones who had the predominat lesion in ENT area.
Point 7:--
Point 8:---

Reviewer 2 Report

Dear Authors, see the attached file, please. It applies for editors and  authors.

Comments for author File: Comments.pdf

Author Response

Response to reviewer number 2

• The selected study is a part of the PhD thesis, which includes other 3 studies related to complex neck traumatology.

The size of the sample (n = 384) is representative of the population of Moldova, the North-East Development Region with a population of about 3,302 million inhabitants. The sampling error was ± 5%. The study group was divided into two groups according to the clinic in which the patients were investigated: 106 patients admitted to the ENT department of "Sf. Spiridon "Emergency Clinical Hospital in Iaşi between 2012 and 2016 and 278 patients from the Institute of Forensic Medicine,Iasi, deceased by complex cervical pathology between 2012 and 2014.  The both of the institution are tertiary hospitals for that region of the country. Patient data collected for this study were kept confidential. This research study was submitted to the analysis and then to the approval by the Ethics Committees of both "Grigore T. Popa" University of Medicine and Pharmacy and the "Sf. Spiridon " Emergency Hospital, Iasi.

The information selected from the observation sheets was in the following categories: demographic data, epidemiological characteristics, lesion appearance and mechanism, cervical location corresponding to defined areas of the neck, type and extent of injured tissues, paraclinical investigations, associated pathologies or recurrences, therapeutic approach, complications and also the data obtained from the regular consultations performed at the hospital discharge.

General exclusion criteria: age under 18 years; the patient's refusal to participate, the presence of cervical trauma in the past but without pathological lesions or only superficial lesions without being accompanied by symptoms.

1. Introduction

Line 43: open and closed – i corrected

Line 44: I corrected the term autolytic with self-inflicted in the entire article.

2. Materials and Methods

The size of the sample (n = 384) is representative of the population of Moldova, the North-East Development Region with a population of about 3,302 million inhabitants. The sampling error was ± 5%. The study group was divided into two groups according to the clinic in which the patients were investigated: 106 patients admitted to the ENT department of "Sf. Spiridon " Emergency Clinical Hospital in Iaşi between 2012 and 2016 and 278 patients from the Institute of Forensic Medicine, Iaşi, deceased by complex cervical pathology between 2012 and 2014. The both of the institution are tertiary hospitals for that region of the country.

3. Results

paragraph 162-166 the data in the text, they do correlate with those in the figure.

In the case study studied on the 384 patients, three predominant mechanisms were identified: self-inflicted, aggression, and accidental. Statistically, the determining mechanism of cervical trauma on both groups was the autolytic one with a percentage of 78.4%, followed by aggression in 14.8% of cases, and last but not least, the accidental mechanism in a percentage of 6.8% (Figure 1). Compared to study groups, the ANOVA test was used to highlight statistically significant percentage differences (p = 0.001): - in group 1 (n = 106), the lesion determining mechanism through aggression (39.6%) was more frequently noticed, followed by the self-inflicted mechanism (39.6%) and the accidental mechanism (22.6%); (Figure 2) - in group 2 (n = 289), in 93.9% of patients the self-inflicted mechanism was present, to the detriment of aggression (5.4%) and the accidental mechanism (0.7%) (Figure 2).

Line 197: I corrected the entire article with roman numerals for the zone classification

Line 206: I replaced the word necropsy with post-mortem examination.

 

Reviewer 3 Report

This topic is interesting, please look at these points:

1. Lines 142-143: "The objectives of the study are to establish the epidemiological, morphopathological, evolution, and social reintegration of complex cervical traumatology cases." The aim of this paper is too general and must be revised, highlighting what this paper add new to the literature.
2. Lines 40-41: "Complex cervical traumas represent an otorhinolaryngological emergency with a constantly increasing incidence" They represent also an important neurosurgical and, often, vascular surgery emergency. Please revise, considering these important papers:   ---Regional and experiential differences in surgeon preference for the treatment of cervical facet injuries: a case study survey with the AO Spine Cervical Classification Validation Group. Eur Spine J. 2021 Feb;30(2):517-523. doi: 10.1007/s00586-020-06535-z.   ----    Anterior cervical corpectomy for cervical spondylotic myelopathy: Reconstruction with expandable cylindrical cage versus iliac crest autograft. A retrospective study. Clin Neurol Neurosurg. 2015 Dec;139:258-63. doi: 10.1016/j.clineuro.2015.10.023. 
3. Lines 49-51: "The diversity of cervical anatomical elements determines the appearance of at least as many types of lesions [3, 4]." Which type of lesions?
4. Lines 281-284: "Herzog et al., ... between the mandible angle and the base of the skull [29]." Cervical trauma is often associated with head trauma, which increases mortality. Please consider these 2 important papers: -- Posttraumatic synchronous double acute epidural hematomas: Two craniotomies, single skin incision. Surg Neurol Int. 2020 Dec 11;11:435. doi: 10.25259/SNI_697_2020.   ---- Head injuries and the risk of concurrent cervical spine fractures. Acta Neurochir (Wien). 2017 May;159(5):907-914. doi: 10.1007/s00701-017-3
5. What about cervical spine fractures? Consider this important AOSpine reference and report your results:   --- Establishing the Injury Severity of Subaxial Cervical Spine Trauma: Validating the Hierarchical Nature of the AO Spine Subaxial Cervical Spine Injury Classification System. Spine (Phila Pa 1976). 2021 May 15;46(10):649-657. doi: 10.1097/BRS.0000000000003873. 
6. Does this paper have any limitations? if yes, please report these limitations at the end of discussion section
7. Lines 315-319: "In a classic study, Asberg et al. describe 315
   the correlation... with low serotonin choose to commit suicide more frequently and use the most violent methods [35]"
8. Lines 328-340. Conclusion should be revised writing what this paper reported and what it apports to the literature.
9. 78.4% of lesione mechanisms are from autolytic ones. How do the authors view this data?

Author Response

Response to reviewer number 3

 

1. Lines 142-143: "The objectives of the study are to establish the epidemiological, morphopathological, evolution, and social reintegration of complex cervical traumatology cases." The aim of this paper is too general and must be revised, highlighting what this paper add new to the literature.

The objectives of the study are to establish the epidemiological, morphopathological, and pathophysiological factors involved in complex neck traumatology, studied on the sample (n = 384) which is representative of the population of Moldova, the North-East Development Region( population of about 3,302 million inhabitants. This is the single study performed in our country related to complex neck traumatology.

2. Lines 40-41: "Complex cervical traumas represent an otorhinolaryngological emergency with a constantly increasing incidence" They represent also an important neurosurgical and, often, vascular surgery emergency. Please revise, considering these important papers:   ---Regional and experiential differences in surgeon preference for the treatment of cervical facet injuries: a case study survey with the AO Spine Cervical Classification Validation Group. Eur Spine J. 2021 Feb;30(2):517-523. doi: 10.1007/s00586-020-06535-z.   ----    Anterior cervical corpectomy for cervical spondylotic myelopathy: Reconstruction with expandable cylindrical cage versus iliac crest autograft. A retrospective study. Clin Neurol Neurosurg. 2015 Dec;139:258-63. doi: 10.1016/j.clineuro.2015.10.023. 

The strenghts of the study consists in amount of cases that we studied, all the severe cases from all over county of Moldova were referred here, being a tertiary hospital unit. Unfortunately, the limitation of the study consists in the fact that de patient with neurosurgical or vasular predominant lesions, we didn’t had the opportunity to include them in study due to the fact that in our city the neurosugical unit is in a separate hospital, we include the ones who had the predominat lesion in ENT area.

3. Lines 49-51: "The diversity of cervical anatomical elements determines the appearance of at least as many types of lesions [3, 4]." Which type of lesions?

We are taking in consideration al the cervical anatomical area included in ENT, starting from the base of the skull to the superior border of thoracic area. All de organs included from the skin,  anterior and lateral cervical fascias and muscles, aero-digestive  tract, salivary glands, thyroid, blood vessel, that could be affect by the mechanism of neck traumatology described in article(Traumatic injuries, which can occur, can be closed or open (penetrating / non-penetrating), and the determining mechanism varies from self-inflicted, aggression, or accidental.)

4. Lines 281-284: "Herzog et al., ... between the mandible angle and the base of the skull [29]." Cervical trauma is often associated with head trauma, which increases mortality. Please consider these 2 important papers: -- Posttraumatic synchronous double acute epidural hematomas: Two craniotomies, single skin incision. Surg Neurol Int. 2020 Dec 11;11:435. doi: 10.25259/SNI_697_2020.   ---- Head injuries and the risk of concurrent cervical spine fractures. Acta Neurochir (Wien). 2017 May;159(5):907-914. doi: 10.1007/s00701-017-3

the limitation of the study consists in the fact that de patient with neurosurgical or vasular predominant lesions, we didn’t had the opportunity to include them in study due to the fact that in our city the neurosugical unit is in a separate hospital, we include the ones who had the predominat lesion in ENT area.

5. What about cervical spine fractures? Consider this important AOSpine reference and report your results:   --- Establishing the Injury Severity of Subaxial Cervical Spine Trauma: Validating the Hierarchical Nature of the AO Spine Subaxial Cervical Spine Injury Classification System. Spine (Phila Pa 1976). 2021 May 15;46(10):649-657. doi: 10.1097/BRS.0000000000003873.

the limitation of the study consists in the fact that de patient with neurosurgical or vasular predominant lesions, we didn’t had the opportunity to include them in study due to the fact that in our city the neurosugical unit is in a separate hospital, we include the ones who had the predominat lesion in ENT area.

6. Does this paper have any limitations? if yes, please report these limitations at the end of discussion section

I added this part in the article  The strenghts of the study consists in amount of cases that we studied, all the severe cases from all over county of Moldova were referred here, being a tertiary hospital unit. Unfortunately,  the limitation of the study consists in the fact that de patient with neurosurgical or vasular predominant lesions, we didn’t had the opportunity to include them in study due to the fact that in our city the neurosugical unit is in a separate hospital, we include the ones who had the predominat lesion in ENT area.

7. Lines 315-319: "In a classic study, Asberg et al. describe 315
   the correlation... with low serotonin choose to commit suicide more frequently and use the most violent methods [35]"

That study describe the correlation between the severity of the mental illness, the level of serotonin in the cerebrospinal fluid, and the chosen suicidal method, revealing that patients with severe psychiatric disorders associated with low serotonin choose to commit suicide more frequently and use the most violent methods. And we correlated to our findings identified the preponderance of male patients over female patients, reflecting the tendency of men to choose an aggressive method, such as strangulation, as a method of suicide. , shooting, stabbing, or road accidents. The predisposing factors identified were alcohol consumption and mental disorders in the personal history.

1. Lines 328-340. Conclusion should be revised writing what this paper reported and what it apports to the literature.

These elements, identified in our study, illustrate the aspects of a real public health problem. Predisposing factors with a predictive role in the production, especially of complex cervical traumas by autolytic mechanism were the association of mental disorders with alcohol consumption. From a social and medical point of view, it is necessary to implement public health policies in terms of preventing the increase of alcohol consumption among the working-age population and a competent assessment in terms of the indication of institutionalized or outpatient treatment, prevention of repeated self-inflicted attempts. or tempting social reintegration.

9. 4% of lesione mechanisms are from autolytic ones. How do the authors view this data?

In the case study studied on the 384 patients, three predominant mechanisms were identified: self-inflicted, aggression, and accidental. Statistically, the determining mech-anism of cervical trauma on both groups was the self-inflicted one with a percentage of 78.4%, followed by aggression in 14.8% of cases, and last but not least, the accidental mechanism in a percentage of 6.8% (Figure 1). Compared to study groups, the ANOVA test was used to highlight statistically significant percentage differences (p = 0.001): - in group 1 (n = 106), the lesion determining mechanism through aggression (39.6%) was more frequently noticed, followed by the self-inflicted mechanism (39.6%) and the accidental mechanism (22.6%); (Figure 2) - in group 2 (n = 289), in 93.9% of patients the self-inflicted mechanism was present, to the detriment of aggression (5.4%) and the accidental mechanism (0.7%) (Figure 2). The data were uploaded and processed using the statistical functions in SPSS 18.0. Significance tests used: t-Student test, F test (ANOVA), Kruskall-Wallis correlation “Pearson” correlation coefficient (r), linear trend((? = ?? + ?).

 

Round 2

Reviewer 3 Report

Authors solved my criticisms.

Author Response

i solved all the indications