Manual Reduction for Subacute Osteoporotic Burst and Severe Compression Thoracolumbar Fractures

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Adding a historical perspective to the introduction would be appropriate.

 

 The methodology of reposition and external fixation in a sling with ligamentotaxis in acute fractures of the Th-L spine was revised by the founder of the English trauma school in the fifties of the twentieth century, Sir R. Watson-Jones. The system of active conservative treatment was further developed in Austria by Lorenz Böhler. He claimed that the same rules apply as for all other fractures and that is reposition and fixation. Subsequently, he fixed it with a plaster corset for 4 months. In this study, there is an innovative method of solving subacute vertebral fractures with the help of traction and subsequent manual reduction.

Comments for author File: Comments.pdf

Author Response

Reply to the reviewer 1.

The methodology of reposition and external fixation in a sling with ligamentotaxis in acute fractures of the Th-L spine was revised by the founder of the English trauma school in the fifties of the twentieth century, Sir R. Watson-Jones. The system of active conservative treatment was further developed in Austria by Lorenz Böhler. He claimed that the same rules apply as for all other fractures and that is reposition and fixation. Subsequently, he fixed it with a plaster corset for 4 months. In this study, there is an innovative method of solving subacute vertebral fractures with the help of traction and subsequent manual reduction.

Thank you very much for your kind review. I have taken your suggestions and changed them in the text, line 39-43.

“The treatment for thoracolumbar vertebral fractures without surgery includes reposi-tion without anesthesia and plaster corset for 4 months, which has evolved from the past one century, from Sir R. Watson-Jones and Lorenz Böhler to the recent advance-ments by Tropiano [6]. However, this method is only suitable for non-surgical cases and is not applicable to open surgery.

Thank you again for your kind review.

Reviewer 2 Report

Comments and Suggestions for Authors

It is not clear what the C image of the Figure 1 stands for. Please explain it under the Figure 2 at the page 4, the rows 136-138.

For the figures 4, 7-11, please decrease the font size for the images (A to F), eventually to 12-14 (apparently the font size is around 18) and, for the consistency of the style, please use the same system for the figure 2, meaning the letters under the images. Or, edit the figures 4, 7-10 and add the letters on the image itself to save the article space. By the way, for the figure 11, the letter B barely can be seen. Some element is on the top of the letter. Edit the image and remove that element.

The images on the Figure 2 and Figure 8 might benefit of increasing a bit the contrast.

Author Response

Reply to the reviewer 2.

Thank you very much for your kind review. I have taken your suggestions and made the changes.

1. It is not clear what the C image of the Figure 1 stands for. Please explain it under the Figure 2 at the page 4, the rows 136-138.

        It is a mistake. The correction has been done as following:

Figure 2. A 90-year-old male was diagnosed with L1 osteoporotic burst fracture (A). Fluoroscopic images show posture reduction (B) and manual reduction (C). The patient was treated with pile-up titanium spacers (D-F). Pre- and postoperative MRI showed spinal cord decompression (G, H).

2. For the figures 4, 7-11, please decrease the font size for the images (A to F), eventually to 12-14 (apparently the font size is around 18) and, for the consistency of the style, please use the same system for the figure 2, meaning the letters under the images. Or, edit the figures 4, 7-10 and add the letters on the image itself to save the article space. By the way, for the figure 11, the letter B barely can be seen. Some element is on the top of the letter. Edit the image and remove that element.

The font size of the figure letters is changed to 12. All the elements within the figure were readjusted and edited carefully. Thank you for your suggestions.

3. The images on the Figure 2 and Figure 8 might benefit of increasing a bit the contrast.                                             For figure 2 and 8, we have tried our best to increase the contrast. Due to the original fluoroscopic images were not clear enough, the pictures in the figures were the clearest we can provide. We are really sorry for that.

Thank you again for your detailed review and helpful suggestions.

Reviewer 3 Report

Comments and Suggestions for Authors

1. The authors provided a description of the manual reduction on 101 patients with subacute osteoporotic thoracolumbar burst fractures and severe compression fractures with 6 team members crucial for reproducibility in clinical practice.

 

2.    The study used post-procedure radiographic outcomes; However, a long-term functional outcome including pain, overall mobility and quality of life scoring is warranted.

 

3.    The statistical analysis is basic. A multivariate regression model could help understanding factors impacting results. 

 

4.    Please give more attention to sentence construction, syntax and grammatical errors.

5.    In the discussion section please compare and contrast the other available treatment options and benefit over it. 

Comments on the Quality of English Language

Table 1: Please change the following terminologies : Falling to fall ; traffic to RTA 

 Introduction section: 

"This retrospective study aims to evaluate the outcomes of 6-member manual reduction for single subacute osteoporotic thoracolumbar burst or severe compression fractures with kyphosis and compare its efficacy with posture reduction, with the goal to deepen our understanding of posture and manual reduction mechanisms."

 

Suggested: "This retrospective study aims to evaluate the outcomes of a 6-member manual reduction technique for single subacute osteoporotic thoracolumbar burst and severe compression fractures with kyphosis, comparing its efficacy with that of posture reduction to deepen our understanding of posture and manual reduction mechanisms."

 

 

Method Section:

 

"Manual reduction could be reiterated as many as needed until anatomic reduction is reached."

 

Suggested: "Manual reduction can be repeated as often as necessary until anatomical reduction is achieved."

 

"The operator compressed the spine to against the trunk motion and induced the realignment of the fractured deformity."

 

Suggested: "The operator compressed the spine against the trunk motion to induce realignment of the fractured deformity."

 

 

Result Section:

 

"The mechanism of injury was falling accidents in 54 patients, traffic accidents in 13 patients, and minor trauma in the remaining 34 patients."

 

Suggested: "The mechanisms of injury included falling accidents in 54 patients, traffic accidents in 13, and minor traumas in the remaining 34."

Author Response

Reply to the reviewer 3.

Thank you very much for your kind review. I have taken your suggestions and changed them in the text.

1. The authors provided a description of the manual reduction on 101 patients with subacute osteoporotic thoracolumbar burst fractures and severe compression fractures with 6 team members crucial for reproducibility in clinical practice.

       Thank you for your accurate and exact focus.

2. The study used post-procedure radiographic outcomes; However, a long-term functional outcome including pain, overall mobility and quality of life scoring is warranted.

   The manual reduction is only a little part of surgery. This brief report focuses only the effects of the technique to reduce the deformity caused by the fractures. The long-term results are more dependent on the subsequent operation procedure to fix the reduced spine. The following procedures are decided by the attending doctors and quite various, including vertebroplasty alone, cemented body cage alone, or combining short or long posterior instrumentation. There will be other papers focus the subsequent operations with mid-term or long-term clinical results. That is why we only analyze the radiographical parameters before and after manual reduction to understanding the effects of manual reduction. The major function of manual reduction is to decrease the subsequent operative procedures, especially and hopefully to avoid the open decompression or instrumentation reduction, which is relatively hard in osteoporotic spine. We will report the long-term clinical outcome in other papers according to your concerns.

3. The statistical analysis is basic. A multivariate regression model could help understanding factors impacting results.

       Thank you for your comments. If this paper reports the clinical outcomes and compared the different subsequent operation methods as mentioned in No.2 response, a multivariate regression model will be important and needed. Surely, we will take your comments in the following papers.

In this paper, without the reports of clinical outcome parameters, the statistical analysis is much easier. After we receive your comments, we re-consult our hospital statistical man for double check. He told us if we did not test other impacting factors, a paired t-test is good for our present study. Because all the data are belonged to the same patients only at different timing, that is, before and after manual reduction. Thank you for your comments again.

4. Please give more attention to sentence construction, syntax and grammatical errors.

       Thank you very much for your comments. Yes, we had done the English editing again.

5. In the discussion section please compare and contrast the other available treatment options and benefit over it.

       For your comments and suggestion, we add the reduction techniques at the pre-surgical era in the introduction section, that is, compared with historical works, as following: (line 39-43)

“The treatment for thoracolumbar vertebral fractures without surgery includes reposition without anesthesia and plaster corset for 4 months, which has evolved from the past one century, from Sir R. Watson-Jones and Lorenz Böhler to the recent advancements by Tropiano [6]. However, this method is only suitable for non-surgical cases and is not applicable to open surgery.”

 

Before operative incision, there are only two methods to do the fracture-reduction, that is, posture reduction and manual reduction. We do the literature review and comparison in 2nd paragraph of the discussion section, line 171-183. Yes, manual reduction benefits over posture reduction.

 

The other operation reduction techniques e.g., instrumentation reduction, is quite different and hard to compare it with manual reduction fairly. Therefore, it is not included in this short report.

 

Table 1: Please change the following terminologies: Falling to fall ; traffic to RTA

 

  It is changed as your suggestion. Thank you.

 

 Introduction section:

"This retrospective study aims to evaluate the outcomes of 6-member manual reduction for single subacute osteoporotic thoracolumbar burst or severe compression fractures with kyphosis and compare its efficacy with posture reduction, with the goal to deepen our understanding of posture and manual reduction mechanisms."

Suggested: "This retrospective study aims to evaluate the outcomes of a 6-member manual reduction technique for single subacute osteoporotic thoracolumbar burst and severe compression fractures with kyphosis, comparing its efficacy with that of posture reduction to deepen our understanding of posture and manual reduction mechanisms."

 

  It is changed as your suggestion. Thank you.

 

Method Section:

"Manual reduction could be reiterated as many as needed until anatomic reduction is reached."

Suggested: "Manual reduction can be repeated as often as necessary until anatomical reduction is achieved."

  It is changed as your suggestion. Thank you.

 

"The operator compressed the spine to against the trunk motion and induced the realignment of the fractured deformity."

Suggested: "The operator compressed the spine against the trunk motion to induce realignment of the fractured deformity."

      It is changed as your suggestion. Thank you.

 

Materials and Methods Section:

"The mechanism of injury was falling accidents in 54 patients, traffic accidents in 13 patients, and minor trauma in the remaining 34 patients."

Suggested: "The mechanisms of injury included falling accidents in 54 patients, traffic accidents in 13, and minor traumas in the remaining 34."

      It is changed as your suggestion. Thank you.

We thank you for your detailed review with your time and efforts to make this brief report closer to perfect.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for making necessary changes and address all the comments . I recommend acceptance of the paper in this revised format.