PONE-D-24-23086Skull-femoral traction followed by osteotomy correction is a safe and effective treatment for severe scoliosis with split cord malformationPLOS ONE

Dear Dr. Guo,

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Barry Kweh

Academic Editor

PLOS ONE

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Comments to the Author

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Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Authors, I had the opportunity to review your article, which addresses a significant topic in orthopedic and spinal surgery: the treatment of severe scoliosis with split spinal cord malformation using craniofemoral traction followed by osteotomy. The topic is relevant and well-chosen, which is why certain sections require substantial elaborations. The introductory section is rather sparse and does not provide adequate context regarding the prevalence of the condition, the main clinical challenges, and the currently available treatment options. It would be beneficial to include a more detailed literature review that explores the effectiveness of alternative treatments and better positions craniofemoral traction within the landscape of therapeutic options. The methods section is generally clear but lacks specific details crucial for the replicability of the study, particularly the inclusion and exclusion criteria. What specific criteria were used to select the 10 patients? Were there any excluded patients, and if so, for what reasons? The description of the traction technique lacks details about the precise protocol followed (e.g., the duration of daily traction sessions, the forces applied, etc.), as well as the potential risks and benefits. The section does not specify whether there were standardized postoperative rehabilitation measures for all patients. This implies that the physician must necessarily provide the patient with all appropriate information about the potential risks, benefits, and specific advantages of one procedure versus another. In this context, I suggest including an article that I recommend citing in your references (https://doi.org/10.1016/j.jflm.2024.102674), which clearly explains that in carrying out a thorough informed consent process, physicians have a professional duty to outline and initiate a discussion about the risks, benefits, and possible alternatives to a given procedure. The results presented are interesting and show significant improvements in various parameters. However, there is a lack of detailed discussion of the statistical analyses used. A more extensive discussion of long-term follow-up data would be useful. For example, how much time was considered in the last follow-up? Were there any cases of scoliosis recurrence or late complications? The data presented are averages, but there is no mention of individual variability among patients. Did some patients respond better to the treatment than others? If so, what factors might explain this variability? The discussion of the results is adequate but could be enriched in several ways. For instance, the section could benefit from a more in-depth explanation of the physiological mechanisms underlying the observed improvements in patients, particularly regarding the improvement in pulmonary function and nutritional status. Additionally, it is important for the authors to acknowledge and discuss the limitations of their study. For example, the sample size is rather small (10 patients), which may limit the generalizability of the results. Moreover, the lack of a control group limits the ability to definitively attribute the observed effects to the specific treatment. In conclusion, the article presents promising results regarding the use of craniofemoral traction followed by osteotomy for the treatment of severe scoliosis with split spinal cord malformation. However, to enhance the scientific and clinical value of the work, more thorough methodological elaboration, a more critical discussion, and an acknowledgment of the study's limitations are necessary. Expanding these sections would significantly improve the robustness and impact of the article.

Reviewer #2: 1. This article is a retrospective study. Only 10 patients were included. Using self-control, whether the number of cases is too small.

2. The surgical methods used by these 10 patients are different. Whether there is a difference in the base number between different surgical methods and whether it has an impact on the postoperative data. If there is any relevant data, please add it.

Reviewer #3: Evaluation of Research Innovation

1. Innovative Aspects:

Novel Treatment Method**: The study employs a novel approach of skull-femoral traction combined with osteotomy correction for treating severe spinal scoliosis accompanied by split cord malformation, which represents a relatively new method in this treatment area.

Comprehensive Assessment Metrics**: The research not only focuses on correcting spinal angles but also encompasses physical indicators such as height, weight, and physiological functions like pulmonary function and nutritional status, which is less commonly seen in similar studies.

2. Research Contributions:

Filling Clinical Practice Gaps: The study addresses gaps in treatment methods for severe spinal scoliosis accompanied by split cord malformation, particularly by avoiding potentially higher-risk procedures like spinous process resection.

Validation of Method Safety and Efficacy: Results indicate that skull-femoral traction followed by osteotomy correction was safe without neurological impairments or major complications during and after treatment. It effectively improves spinal deformities and physiological parameters, offering significant guidance for clinical practice in this patient group.

3. Suggestions for Improvement:

Long-term Follow-up Data: To further validate the method's long-term effects and stability, it is recommended to include extended follow-up data, particularly beyond one year post-treatment.

Exploration of Additional Physiological Parameters: In addition to the assessed metrics, consider adding other physiological parameters such as further analysis of cardiopulmonary function or assessment of patient quality of life to comprehensively evaluate treatment outcomes.

In summary, this study demonstrates innovation in method selection and comprehensive assessment, with clear potential contributions to clinical practice. However, there is room for further optimization and enhancement to improve the study's comprehensiveness and scientific rigor.

Abstract

Areas for Improvement:

Issue: The abstract is detailed but lacks conciseness, resulting in lengthiness that may overwhelm readers seeking a quick overview.

Recommendation: Simplify the presentation by focusing on essential findings and consider omitting specific numerical data that can be detailed in the main text. Enhance readability by streamlining the language.

Addressing these aspects will enhance the abstract's clarity, accessibility, and effectiveness in conveying the study's significance and findings within the orthopedic research community.

Introduction

The introduction to this study excels in describing background and conducting a literature review. However, enhancing methodological comparisons and future research prospects could further elevate its scientific value and academic contribution.

Areas for Improvement:

While the introduction provides comprehensive background and literature support, it could further emphasize the limitations of current treatment methods and potential directions for future research to enhance the optimization and innovation of treatment approaches.

It is recommended to include comparative analyses of other treatment methods, particularly effectiveness and pros and cons compared to skull-femoral traction followed by osteotomy correction, to enhance the study's academic depth and practical relevance.

Evaluation of Research Methodology

1. Methodological Strengths:

Comprehensive Approach: The study employs a comprehensive methodology that includes detailed pre- and post-treatment assessments of various parameters such as spinal angles, physiological measurements (e.g., VC, FVC, FEV1), and biochemical markers (e.g., albumin, transferrin). This approach provides a thorough evaluation of the treatment's effects on both structural and functional outcomes.

Longitudinal Assessment: The use of multiple follow-up points (after traction, after corrective surgery, and at the last follow-up) enhances the reliability of the findings by capturing changes over time and assessing the sustainability of treatment outcomes.

Absence of Complications: The study reports no neurological impairments or significant complications related to the traction or osteotomy procedures, indicating careful procedural management and patient monitoring.

2. Areas for Improvement:

Sample Size and Diversity: The study's sample size of ten patients limits the generalizability of findings. Including a larger and more diverse patient cohort could strengthen the study's external validity and allow for subgroup analyses based on different patient characteristics.

Control Group or Comparative Analysis: Introducing a control group or comparative analysis with alternative treatment methods would provide a clearer basis for evaluating the specific benefits of skull-femoral traction followed by osteotomy correction compared to standard treatments.

Data Standardization: Ensure consistent data collection protocols across all measurements to minimize variability and enhance the reliability of comparisons over time.

3. Data Analysis:

Statistical Rigor: The statistical analysis appears appropriate for the study's objectives, utilizing descriptive statistics and measures of central tendency to summarize continuous data. However, considering the complexity of the data (e.g., longitudinal measurements), employing more sophisticated statistical methods such as repeated measures ANOVA or mixed-effects models could provide deeper insights into treatment effects over time.

In conclusion, while the study demonstrates methodological rigor in its approach to evaluating skull-femoral traction followed by osteotomy correction for severe spinal scoliosis with split cord malformation, there are opportunities for enhancement, particularly in sample size, comparative analysis, and data standardization, to further strengthen the validity and generalizability of its findings.

Results

Areas for Improvement:

1. Clarity and Logic of Data Presentation:

Issue: Some sections of data presentation may be too compact, making it challenging for readers to follow, especially in describing different patient scenarios.

Recommendation: Consider reorganizing the data, such as through clearer segmentation to distinguish between different cases and treatment effects. Ensure each case description is clear and structured to facilitate reader comprehension of the study's progression.

2. Statistical Analysis and Significance:

Issue: Descriptions regarding statistical significance should be more detailed and thorough to ensure readers have a clear understanding of the reliability of the results.

Recommendation: Clearly state the methods of statistical analysis and significance levels (e.g., P-values) in each results subsection, and discuss their implications for interpreting the study findings.

3. Use of Figures and Tables:

Issue: The results section could benefit from additional figures and tables to enhance the visual representation of data, aiding readers in quickly and intuitively grasping key findings.

Recommendation: Consider adding relevant figures and tables to the results section to showcase primary data and trends. This will highlight key results and improvement trends from the study.

Discussion

Clarity of Logic and Structure:

Issue: The viewpoints and research findings in the discussion could be more clearly organized and presented, especially in describing different cases and treatment outcomes.

Recommendation: Consider reorganizing the discussion content to ensure there is a clear logical flow between each viewpoint and research result. Enhancing overall coherence with clearer paragraph structures and topic sentences would facilitate easier understanding and follow-up of the discussion's progression.

Conclusion

Please include a conclusion section at the end of the paper to match the abstract.

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Reviewer #1: Yes: Giuseppe Basile

Reviewer #2: No

Reviewer #3: No

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PONE-D-24-23086R1Skull-femoral traction followed by osteotomy correction is a safe and effective treatment for severe scoliosis with split cord malformationPLOS ONE

Dear Dr. Guo,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Sep 26 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Barry Kweh

Academic Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments:

A further discussion of the long-term follow-up and medical complications of the disease would improve the manuscript.

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Skull-femoral traction followed by osteotomy correction is a safe and effective treatment for severe scoliosis with split cord malformation

PONE-D-24-23086R2

Dear Dr. Guo,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Barry Kweh

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

A well written article which has justified statistical methods and significantly improved the depth as well as breadth of the discussion.

Reviewers' comments: