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Int J Surg
Int J Surg
JS9
International Journal of Surgery (London, England)
1743-9191
1743-9159
Lippincott Williams & Wilkins Hagerstown, MD

IJS-D-24-02048
10.1097/JS9.0000000000001726
00121
3
Correspondence
A comment on ‘Clinical efficacy of different surgical approaches in the treatment of thoracolumbar tuberculosis: a multicenter retrospective case-control study with a minimum 10-year follow-up’
Xie Chengxin MD chengxin_xie@163.com

Li Yimin MS liym5720@enzemed.com

Luo Hua MM *luoh5367@enzemed.com

Department of Orthopedic, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, People’s Republic of China
* Corresponding author. Address: Department of Orthopedic, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, No. 150 Ximen Road, Taizhou 317000, Zhejiang, People’s Republic of China. Tel.: +86 158 586 76570. E-mail: luoh5367@enzemed.com (H. Luo).
9 2024
29 5 2024
110 9 59855986
14 5 2024
19 5 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

OPEN-ACCESSTRUE
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pmc Dear Editor,

We recently read the article ‘Clinical efficacy of different surgical approaches in the treatment of thoracolumbar tuberculosis: a multicenter retrospective case-control study with a minimum 10-year follow-up’ authored by Professor Liu et al.1. The study evaluates the effectiveness of three distinct surgical approaches for treating thoracolumbar spinal tuberculosis, focusing on clinical manifestations, postoperative Cobb angle, and complications. The authors suggest employing the anterior approach for cases with localized lesions and minor angle deformities. Conversely, for patients presenting with multisegmental lesions and significant angular deformities, they recommend either a posterior approach or a combined anterior and posterior approach, with the posterior approach favored as the primary option. While we appreciate the valuable contribution made by the authors, we believe that there are still some areas in this study that require further exploration.

First, in the article, the author described a procedure involving aspiration of pus using a syringe followed by irrigation with hydrogen peroxide and normal saline to eliminate residual pus and necrotic tissue. Hydrogen peroxide (H2O2) catalase is ubiquitously found in various human organs and tissues, whereupon contact rapidly decomposes H2O2 into oxygen and water. Zhang and Jia reported the exist of fatal complications, such as gas embolism and pneumocephalus, arising from the use of hydrogen peroxide irrigation2. The precise mechanism by which H2O2 and the resultant oxygen bubbles enter the bloodstream remains incompletely understood. Nonetheless, the author’s advocacy for hydrogen peroxide irrigation lacks substantiated safety measures and empirical medical evidence. This is because the copious oxygen bubbles generated post-irrigation do not promptly dissolve and disperse but rather become trapped within the right atrium or pulmonary arteries during transit through the circulatory system. In addition to cardiovascular gas embolism, H2O2 and oxygen bubbles may ascend, accessing intracranial tissues via ruptured epidural venous plexuses or the epidural or subdural space, culminating in direct neurotoxicity, intracranial gas accumulation, and cerebral vascular infarction. Although the author did not report the incidence of related complications, we discourage the use of hydrogen peroxide irrigation within enclosed cavities in the absence of corroborating evidence.

Second, in discussing the dosage of anti-tuberculosis treatment, the author specified: ‘HRZE regimen for 4–8 weeks (H: isoniazid, 0.3 g/day; R: rifampicin, 0.6 g/day; Z: pyrazinamide, 0.75 g/day; E: ethambutol, 0.75 g/day; with slight adjustments in drug dosage based on patient weight and age).’ However, it is essential to ensure that patients receive an adequate dosage of anti-tuberculosis medication. According to previous research, patients weighing between 56 and 75 kg should ideally receive daily doses of 1.5 g of pyrazinamide and 1.2 g of ethambutol3. The dosages mentioned by the author in the manuscript fall significantly below these recommended levels. Furthermore, the author mentioned a continuation of anti-tuberculosis treatment for 12–18 months post-surgery without specifying the subsequent chemotherapy regimen. According to WHO guidelines, the HRZE combination therapy is utilized solely during the intensive phase for newly diagnosed tuberculosis patients, after which adjustments to the anti-tuberculosis drugs are necessary4. Providing detailed descriptions of the subsequent chemotherapy regimen would significantly enhance the persuasiveness of the article.

Third, in the Results section, the author stated, ‘The three groups had no significant differences regarding gender, age, and hospitalization duration (P<0.05).’ I believe it should be ‘(P>0.05)’ here. The author mentioned in the text, ‘At the same time, there was no significant difference between the AO and AP groups (P>0.05) (Table 1).’ It seems the author intended to refer to the ‘AO and PO groups.’ Besides, the tables (Tables 1–3) employ superscript letters (a, b, c, d, f) without corresponding explanations provided below the tables regarding their significance. Furthermore, Table 5 is lacking a table note.

Notwithstanding the raised concerns, we express our sincere appreciation for the significant contribution made by the author in this field. We trust that our suggestions may prove beneficial for the author’s future research endeavors, and we eagerly anticipate their feedback and recommendations.

Ethical approval

Not applicable.

Consent

Not applicable.

Source of funding

This study was supported by the Zhejiang Medicine and Health Scientific Research Project (No. 2024KY531).

Author contribution

H.L.: proposed the design, collected, and wrote the study; C.X. and Y.L.: collected the study.

Conflicts of interest disclosure

There are no conflicts of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Hua Luo.

Data availability statement

This commentary does not involve any data.

Provenance and peer review

Commentary, internally reviewed.

Acknowledgements

Not applicable.

C.X. and Y.L. have contributed equally to this work and share first authorship.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 29 May 2024
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References

1 Liu R He J Fan Q . Clinical efficacy of different surgical approaches in the treatment of thoracolumbar tuberculosis: a multicenter retrospective case-control study with a minimum 10-year follow-up. Int J Surg 2024. doi:10.1097/js9.0000000000001272
2 Zhang K Jia H . Simultaneous gas embolism and pneumocephalus after paravertebral irrigation with hydrogen peroxide: a rare case report. Int J Surg Case Rep 2024;116 :109387.38367418
3 Nahid P Dorman SE Alipanah N . Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016;63 :e147–e195.27516382
4 Blumberg HM Burman WJ Chaisson RE . American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. Am J Respir Crit Care Med 2003;167 :603–662.12588714
