Letter to editor: Feedback on “comprehensive spinal tuberculosis score: clinical guide for the management of thoracolumbar spinal tuberculosis”
Article information
Dear Editor,
We recently had the opportunity to delve into the insightful article authored by Sonawane et al. [1]. We commend the authors for their diligent work; nevertheless, we have several observations to share regarding the content of this study.
(1) The results section primarily focuses on pain resolution as indicative of the disease process. While pain severity correlates with spinal column destruction, other critical factors such as instability during weight-bearing or positional changes in bed should not be overlooked. Relying solely on pain severity may yield ambiguous results, given the diverse spectrum of spinal tuberculosis presentations. Patients exhibiting low Visual Analog Scale back pain alongside instability are potentially better predictors of underlying spinal instability [2].
(2) Within the methodology section, the calculation of vertebral body loss is addressed. The utilization of the “eyeballing” method for quantifying vertebral body loss is noted. However, this approach is crude and lacks standardization. Employing various radiometric tools for estimating vertebral body loss would provide more accurate assessments and precise representations of spinal instability [3].
(3) Further, the methodology section lacks clarity concerning the inclusion criteria based on compression of the spinal cord in imaging studies. There appears to be a lack of consensus regarding the criteria for grading neurological deficits. Objective criteria for defining non-compressive neurological deficits have not been established. Failure to include milder grades of neurological deficits may introduce bias into the study’s findings.
(4) The retrospective evaluation of the score is discussed in the results section. However, the importance of prospective evaluation, crucial for the development and validation of the scoring system, seems to have been overlooked. Prospective analysis, along with inter-observer reliability assessments, is essential but regrettably absent in the current study.
(5) As outlined in the introduction, the scoring system aims to establish criteria for surgery in all cases of spinal tuberculosis. However, its applicability seems limited to classical paradiscal lesions, excluding atypical spinal tuberculosis patients. This discrepancy contradicts the initial objective of the scoring system.
(6) All 151 patients were managed by the same surgeon at a single center, implying a gold standard of management based on outcomes. However, this raises concerns about potential bias, as management decisions by other practitioners may differ.
(7) The dynamic nature of spinal tuberculosis complicates assessment. A scoring system at presentation may lead to flawed decisions; a patient initially surgical may respond to chemotherapy, later requiring conservative management. The study fails to address this ambiguity.
(8) The study neglects age as a scoring criterion, crucial in pediatric spinal tuberculosis. Younger patients often suffer severe deformities and neurological issues, not adequately addressed by general guidelines. Many studies suggest that being under the age of 10 years is associated with progressive spinal deformity despite conservative management, indicating underlying instability [4].
In conclusion, while we commend the authors for their contributions, we believe that addressing the concerns raised would enhance the quality and applicability of this study, thus benefiting its readership.
Notes
Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Author Contributions
Planning of study: PB, PK, KA. Writing: PB. Revising the manuscript: PB, PK, KA. Reviewing the study: SS. Final approval of the manuscript: all authors.