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Q: The paper mentions several surrogate end points, but there is no clear primary outcome measure. Should the most important outcome measure for thoracolumbar fractures with neurological compromise not be recovery of neurological deficit? There is also no mention as to what the degree of neurological injury is. Were there any isolated nerve root injuries included?
A: The primary outcome in thoracolumbar fracture patients with neurological deficits is the improvement of neurological functions. In our study, we assessed the function by the Japanese Orthopaedic Association (JOA) score system and the change in American Injury Spinal Association (ASIA) grade pre- and postoperatively.
Q: Thoracolumbar fractures have a high incidence of associated injuries such as visceral injuries and long bone fractures. Were patients with associated injuries of any type excluded from this study? Would these associated injuries have an influence on the JOA and Visual Analog Score (VAS) scores?
A: The patients with associated injuries were not excluded in our study. Patients with visceral injuries were first sent to associated department for the treatment of other injuries. When it is stable, if it is still within 3 weeks, the fracture is treated with surgery in our department. In our study, the patients were randomly assigned to two groups and there is no difference in baseline of VAS and JOA score. So the influence of associated injuries can be excluded. For the patients with long bone fracture, the influence on the JOA is obvious, because the score system contains movement of upper or lower limb. However, no other scoring system can eliminate the influence of the movement of limb, even SF-36 (The Short form(36) Health Survey).
Q: We would question the authors’ statement that a VAS improvement of one point is clinically significant. To our knowledge, the JOA is a validated measure of cervical myelopathy and is an interesting choice. Data regarding bladder and bowel function and improvement in ASIA score would be useful as well as a patient-reported outcome measure such as the SF-36.
A: Indeed, SF-36 is an excellent measurement for neurological function. However, JOA score is also widely applied in the assessment of the neurological status in thoracolumbar fracture1 and it is more objective than SF-36. SF-36 is a subjective scoring system and it relies more on the educational level of patients. In China, many patients, especially the thoracolumbar fracture patients, are under-educated, thus it is hard for them to fully understand the content of SF-36, which would lead to mistakes in assessment of patient status.

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