I appreciate your feedback on our recently published article [1], “Do different pathologies of adult spinal deformity (idiopathic lumbar scoliosis against de novo lumbar scoliosis) affect preoperative and postoperative selfimage?” We value the insights you’ve provided and are grateful for the opportunity to address your concerns.

Firstly, regarding the discrepancy in patient numbers, our study initially enrolled 85 patients, but after applying inclusion and exclusion criteria, the final cohort consisted of 60 patients, as described in the results in the first paragraph and Fig. 1 of our study [1]. We apologize for any confusion caused.

Regarding the eligibility criteria, we acknowledge the importance of transparency in patient selection. Our criteria included adult patients diagnosed with idiopathic or de novo scoliosis who underwent corrective surgery and had a follow-up period of at least 2 years at our hospital. As mentioned in the results, the number of fused segments was 9.8±1.7, indicating that patients in this study cohort required long fusion surgery, which mainly aims to correct spinal malalignment rather than short fusion to correct focal alignment.

We agree that clearer subheadings and adherence to journal guidelines for the materials and methods section are essential. Although we included six subheadings in this manuscript, the study design was not clearly delineated and was instead mentioned in the ethical statement. We also appreciate the feedback regarding the lack of registration and trial dates. This study is a retrospective cohort study and included patients from January 2009 to December 2020. Thank you for giving us the opportunity to clarify these details and improve the quality of the paper.

We appreciate your point about confounding variables such as pain levels, functional status, and psychological conditions. We completely agree with this opinion. Therefore, we excluded patients with depression or antidepressant use before the analysis. Additionally, in the subgroup analysis, we tried to minimize the differences between the adult idiopathic scoliosis (AdIS) and de novo groups using propensity score matching to adjust for patients’ age, sex, preoperative physical component summary and mental component summary scores, and the subtotal score of the Scoliosis Research Society-22 revised (SRS-22r). This subgroup analysis consistently showed that the self-image domain of the SRS-22r at 2 years after surgery was significantly different between the two groups and supported our results.

Furthermore, your point about patients’ gender is critical regarding self-image. Although we did not intentionally exclude male patients from the analysis, there were no male patients with adult spinal deformity who were previously diagnosed with adolescent idiopathic scoliosis at our hospital. While we tried to adjust for the gender effect on self-image using multivariate analysis, the self-image of male patients with AdIS might be a topic for future research.

Lastly, we recognize that a longer follow-up period would offer a better understanding of the long-term effects of surgery on self-image. We mentioned this as a limitation and suggest that future studies aim for extended follow-up periods to capture these effects.

In conclusion, we are grateful for your constructive feedback. We believe that addressing these areas will enhance the value of our research and provide clearer insights for readers. Although this paper has several limitations, we believe it represents a first step for spine surgeons to classify AdIS from de novo scoliosis not only based on pathology but also on clinical aspects. Thank you for the opportunity to respond and improve our work.