Dear Editor,

We read with great interest the paper by Qian et al. [1] entitled “Outcomes of radical debridement versus no debridement for the treatment of thoracic and lumbar spinal tuberculosis” published online in June 2016 in International Orthopaedics. In this randomized study, the authors demonstrated that single posterior instrumentation without debridement with minor surgical trauma, fewer complications, and spontaneous fusion, can recieve good clinical outcomes as the anterior approach with debridement. It is a very valuable study. Nevertheless, there are some questions we would like to raise related to this article.

It is a randomized study. All patients were selected according to the same inclusion and exclusion criteria. The article referred to the inclusion criteria containing Frankel grading was grade D and E, severe back pain, larger sequestrum formation, and significant spinal instability. This inclusion criteria is extensive. Some with atypical spinal tuberculosis, such as posterior elements involvement meeting the inclusion criteria, may not be suitable to receive anterior approach intervention. Additionally, this could produce selected bias. Anterior surgery was generally avoided in patients with lesions above T6 (as instrumentation above T5 body is difficult), in patients with kyphosis more than 60°, and in patients with a bad pre-operative chest and abdominal conditions [2]. We authors feel that the relevant characteristics of patients which may fully affect the surgical decision in this article need to be similar in order to ensure the clinical efficacy validity between the comparison of the two approaches.