Letter to Editor on “Management of Aggressive Vertebral Haemangioma and Assessment of Differentiating Pointers Between Aggressive Vertebral Haemangioma and Metastases – A Systematic Review” by Subramaniam et al

I read the systematic review on the management of aggressive vertebral haemangiomas (AVH) and the assessment of the differentiating pointers between an AVH and metastasis with great interest and attention. ¹ The authors have identified 8 studies on the management of AVH and 3 studies for radiological differentiating pointers between AVH and metastasis from their search in the 3 databases included for analysis. Considering the representation of the results of the studies included, I have some concerns with the authors' interpretation.

First, in the percutaneous vertebroplasty section, the authors used a Visual Analog Scale to give the outcomes while Narayana et al ² used a pain intensity numeric rating scale (PI-NRS). Although both scales have a high degree of agreement, both are not the same. ³ Moreover, the values presented seem to be flawed. The mean preoperative PI-NRS from the study was 8.5 (Range 7-10) which reduced to the postoperative PI-NRS of .7 (Range 0-3) at 6 months follow-up. ² Hence, the author’s representation of the content in Figure 2 is also flawed.

Second, in the surgery section, the references added for the patients undergoing alcohol ablation with posterior decompression and patients undergoing anterior corpectomy and reconstruction with prior feeding vessel embolization were wrong. Actually, Nair et al ⁴ specifically excluded the patients who opted for embolization in their series and mentioned that the procedure failed to reduce intraoperative bleeding in their institute since the vertebral bodies were found to be collapsed and converted into a solid mass. But the authors have included this study under the preoperative embolization category which is wrong.

Moreover, Nair et al ⁴ in their study presented the blood loss to be in the range of 1.5 – 3 L and I wonder how the authors arrived at the mean value of 2100 mL. Hence, the content in Figure 4 and Table 5 represents flawed data and improper categorization of studies. Authors have strongly advocated against preoperative embolization with this misinterpretation of studies which warrants a revision of their content. Similarly, the study by Prabhuraj et al ⁵ is categorized as perioperative embolization which is actually per-operative glue embolization.

Lastly, the authors have adapted several images from the included studies without any citation in the figure legends, for eg Figure 9, which needs to be emphasized by the editorial team.

I congratulate the authors for their wonderful work but I wish to state these flaws and suggest their necessary revision in a reply to this letter as an addendum for the benefit of the audience who might take the content in reputed journals such as Global Spine Journal granted to be precise. I consider Global Spine Journal to be of high standards and I expect the authors and the editorial team to keep up the standards through rigorous scrutiny of the data in the manuscripts submitted for publication.