We read with great interest an article titled “Letter to the editor: Factors related to surgical site infection in spinal instrumentation surgery: a retrospective study in Japan” [1]. The authors made significant contributions by identifying factors involved in surgical site infection (SSI) in spinal instrumentation surgery. However, we would like to highlight several key points that we believe are crucial for readers to fully understand the study’s implications. These points are discussed in more detail below:

Although the study analyzed numerous factors influencing the incidence of SSI, certain potential contributors have not been addressed, such as perioperative medication use (e.g., antibiotics, immunosuppressants), the choice of surgical disinfectants, and the wound closure techniques. Furthermore, while the article indicates no significant difference in the prevalence of diabetes between the two groups, perioperative blood glucose levels were not recorded. It is important to note that the primary cause of SSI is not diabetes itself, but rather hyperglycemia. This becomes particularly relevant in the context of corticosteroid use in a significant portion of patients, making the monitoring of blood glucose even more critical. Previous studies have indicated that these factors may influence SSI rates in spinal instrumentation surgeries [2,3]. Our unpublished data from the medical center also suggest that these variables could be potential contributors to SSI. Moreover, the study spans data collected from 2013 to 2021, a period during which significant advancements in surgical techniques and perioperative management have occurred [2]. These changes could impact the incidence of SSI and the identification of associated risk factors. However, the study may not have fully accounted for these temporal trends.

Despite the arguments presented in this discussion, the article’s contributions are undeniably substantial. Nevertheless, as dedicated researchers, we must acknowledge that there is always room for improvement. We believe it is necessary to conduct more in-depth analyses and investigations on these factors in future studies. Should any confounding factors come to light, it is imperative that they be thoroughly accounted for, thereby enhancing our overall understanding of the study.