Response to the Letter to the Editor: Lumbar transforaminal injection of steroids versus platelet-rich plasma for prolapse lumbar intervertebral disc with radiculopathy: a randomized double-blind controlled pilot study

Article information

Asian Spine J. 2024;18(3):489-490

Publication date (electronic) : 2024 June 26

doi : https://doi.org/10.31616/asj.2024.0109.r2

Anuj Gupta¹, Harvinder Singh Chhabra^,2, Vishwajeet Singh³, Daram Nagarjuna⁴

¹Department of Spine Surgery, Max Superspeciality Hospital, Ghaziabad, India

²Department of Spine Surgery, Sri Balaji Action Medical Institute, New Delhi, India

³Winnipeg Spine Program, University of Manitoba, Winnipeg, MB, Canada

⁴Indian Institute of Technology, New Delhi, India

Corresponding author: Harvinder Singh Chhabra, Department of Spine Surgery, Sri Balaji Action Medical Institute, New Delhi, India Tel: +91-011-4288-8135, E-mail: drhschhabra@gmail.com

Received 2024 April 16; Accepted 2024 April 29.

Dear Editor,

We want to thank the authors of the “Letter to the Editor” for their interest in our pilot study [1], which compared lumbar transforaminal injection of steroids and platelet-rich plasma for patients with prolapsed lumbar intervertebral disc with radiculopathy in a randomized double-blind controlled trial. We appreciate and welcome their comments and would like to address them in this forum.

We would like to reiterate that PICO guidelines suggest to frame a research question which involves P (Population/Patient/Problem), I (Intervention), C (Comparison), and O (Outcome). These guidelines help to construct a meaningful and valid research design [2]. It is always better to include these points in the title of the article and if not, the abstract should definitely contain them [3]. Moreover, another significance to include them in title is that it increases the visibility of the article during search in different search engines like PubMed [4]. The authors of “Letter to the Editor” suggested modifying our study’s title using the PICO guidelines to make it more informative. While we acknowledge that adding the term “comparison of effectiveness” could have improved the searchability and aligned with the study’s objectives, we believe that our current title is self-explanatory. It clearly states that our study compares the effects of two methods on lumbar disc herniations. Moreover, we have reiterated the study’s objectives in the ‘purpose’ section of the abstract to ensure consistency with the title. Furthermore, we believe, more popular keywords for search among these group of articles would be ‘PRP’ or ‘lumbar transforaminal injection,’ keywords we have already used in the manuscript.

The author colleagues have suggested that this is a comparative study and should have a study hypothesis. As mentioned, there was only one published study before the submission of this manuscript and this was taken up as a pilot study. We had no presumptions about the difference between the interventions studied. Considering the nature of study as pilot study and unavailability of enough literature on the topic, we compared the two similar groups using various parameters like mean and median. This got validated since skewness suggests almost symmetric data. However, taking into consideration factors of age as well as gender and the parametric differences of Visual Analog Scale, modified Oswestry Disability Index, and Short-Form 12 in each group, we chose to use Mann-Whitney U test. For our subsequent larger trial, we will consider a hypothesis for superiority or equivalence of the interventions.

The authors are also concerned about the inclusion criteria. We want to clarify that patients older than 18 years and younger than 60 years were included. All patients at the primary institution were treated conservatively, and those who failed to respond were offered injections. The disease duration varied among the participants, and the criteria for offering injections was patients’ subjective failure to cope with pain symptoms irrespective of the onset of symptoms. However, at least 6 weeks of conservative management before any invasive procedure like lumbar transforaminal injection is our regular practice. Moreover, we cannot change the inclusion-exclusion criteria after completing the study. These were decided when the study was started to achieve the most appropriate cohort required for the study.

We also acknowledge that the sampling method employed was convenience sampling, and every consecutive lumbar disc herniation patient had an opportunity to be enrolled in the study. The underlying data distribution was tested for normality using mean and standard deviation as described in the data in Table 1 of our study [1]. We did not use any software for the pilot study but data was analyzed with appropriate parameters to justify the use of mentioned test.

Again, we acknowledge the authors’ comments and thank them for providing the opportunity to further elaborate on the study’s methodology and findings. We believe these comments have refined the study’s message for the readers and have substantially contributed to it.