Comparison of short segment posterior spinal fixation with or without index screw in thoracolumbar spinal injuries – mid-term results

Research Article

Comparison of short segment posterior spinal fixation with or without index screw in thoracolumbar spinal injuries – mid-term results

  • Bharat Bhushan 1
  • Ayush Sharma 2
  • Vivek P Ksheerasagar 3*
  • Tharun Teja 4
  • Akash Kumar Ghosh 5

*Corresponding Author: Vivek P Ksheerasagar., Senior Resident, Indira Gandhi medical college1, Shimla, India.

Citation: Bhushan B., Sharma A., Vivek P. Ksheerasagar., Teja T., Akash K. Ghosh, et al, (2024), Comparison of short segment posterior spinal fixation with or without index screw in thoracolumbar spinal injuries – mid-term results, Journal of Clinical Surgery and Research, 5(7); DOI:10.31579/2768-2757/140

Copyright: © 2024, Vivek P Ksheerasagar. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 21 August 2024 | Accepted: 16 September 2024 | Published: 16 October 2024

Keywords: thoracolumbar spinal injuries; posterior fixation; index screw fixation

Abstract

Introduction: Short-segment spinal instrumentation has been advantageous in the treatment of thoracolumbar spinal fractures for better correction of kyphotic deformity. Many authors considered that together with the rods with lordotic contour, pedicle screw fixation at the fractured vertebra can cause a forward driving force to augment the reduction, and help to directly elevate the end plate to assist in the restoration of the compressed vertebral height. So it is worthwhile to study the functional and radiological outcome of short-segment fixation of thoracolumbar spine fracture with or without an index screw.

Material and methods: A total of 108 patients (44 retrospective and 64 prospective) underwent posterior stabilisation with pedicle screws and rod construct under radiographic guidance. The only difference in the two groups is the insertion of an index screw in the fractured vertebra. Neurological and functional outcomes of all patients were analysed with the ASIA scale, Denis pain score and Denis work scale preoperatively, postoperatively and at 9 months. Radiographic assessment was done with a preoperative radiograph and CT scan measuring regional kyphotic angle at preoperative, postoperative and final follow-up.

Results: Of the total 108 patients with dorsolumbar vertebral fracture- Group-A had 28 patients without index screws, Group-B had 80 patients with index screw in the fractured vertebra. Postoperatively, we found neurological improvement by 1 grade according to the ASIA scale but there was no significant difference between the two groups. We found no significant difference in the neurological and functional outcomes but the change in kyphotic angle between the immediate postoperative period and 9 months follow-up was significantly less in group B.

Conclusion: The addition of an index screw in the thoracolumbar fractures will help in better kyphosis correction, less correction loss in kyphotic angle in the postoperative period with fewer instrument failures, without additional complications.

Introduction

With increasing roadside accidents, falls and industrialization spine injuries are increasing day by day, usually associated with high-energy trauma. Dorsolumbar spinal injuries account for 30-50% of all spine injuries [1]. Dorsolumbar injuries in trauma are seen at the dorsolumbar junction, with 60% occurring between T11 and L2 vertebral level, and 10-14% involving the lower lumbar spine. Around 20% of patients with fractures at thoracolumbar level have neurological injuries [2]. The susceptibility of the thoracolumbar junction is mainly due to there is transition from more rigid kyphosis of the thoracic region to mobile lordosis lumbar region [3]. This zone of transition is susceptible to substantial biomechanical stress during traumatic incidents, making it more vulnerable to fracture. It is a grave injury that can cause significant morbidity and disability to the patient.

The goal of surgery in these fractures includes decompression of the neural components, reduction of fracture, providing a rigid fixation, and rehabilitation of the patient. If surgical treatment of thoracolumbar spine fracture is decided further debate arises on the type of approach [4]. Anterior decompression with stabilization has been suggested for cases with severe spinal canal narrowing, severe comminution or dislocation, and neurological deficit. However, the posterior approach is less extensive, and many surgeons advocate short-segment spinal instrumentation. Recent literature shows that circumferential decompression with stabilization of the fracture can be done through the posterior approach alone with good results thereby reducing the surgical time, blood loss, infection, overall morbidity and complications seen with the anterior and combined approach. Short-segment spinal instrumentation has been advantageous in the treatment of thoracolumbar spinal fractures for better correction of kyphotic deformity with greater initial stability, early painfree mobilisation, and indirect decompression of the spinal canal.

Many authors considered that together with the rods with lordotic contour, pedicle screw fixation at the fractured vertebra can cause a forward driving force to augment the reduction and reshaping. Also, the screw put at the fractured vertebra can be used to directly elevate the end plate to assist in the restoration of the compressed vertebral height. A screw inserted at the fractured vertebrae can reduce the stress of screws in the upper and lower normal vertebrae to decrease the incidence of fracture of screws [5]. Surgeons who advocate these implants for dorsolumbar instability after a burst fracture suggest augmentation with anterior column support to avoid excessive cantilever loads on the screws that might lead to bending failure or breakage. So, it is worthwhile to study the functional and radiological outcome of short segment fixation of thoracolumbar spine fracture with or without one screw fixation in fracture vertebrae. Hence this study is designed to evaluate the result after short segment fixation one level above and one level below and one screw in fracture vertebrae (index screw) and to compare to fixation one level above and one below.

Objective:

To compare the radiological and clinical outcome of short segment posterior spine stabilisation for thoracolumbar injuries with or without index screw.

Material and methods:

A total of 108 patients (44 retrospective and 64 prospective) operated at the Department of Orthopaedics at Indira Gandhi Medical College, Shimla were included in the study. Clearance from the ethics committe was taken from the institutional ethical review committee and informed consent was taken from the patients. 

Inclusion criteria

  1. Patient with unstable fracture at thoracolumbar region.
  2. Patient with or without neurological deficit or partial neurological involvement.
  3. Age group of 16 to 70 years.
  4. Patients with TLISS Score 4 or more. 

Exclusion criteria

  1. Patient with stable thoracolumbar injuries. 
  2. Patient with co-morbidities conditions and not fit for surgery.
  3. Patients with fractures at multiple levels.

The patients included in the study were thoroughly evaluated on admission and were taken up for posterior stabilisation of the thoracolumbar injury in a prone position using a midline open approach with pedicle screws and rod construct under radiographic guidance. The only difference in the two groups is the insertion of an index screw in the fractured vertebra. Laminectomy is done in cases where canal diameter is decreased by more than one-third and the patient has a neural deficit. Sometimes dural tear was found due to the bony fragment injuries. The dural tear was repaired with 3-0 silk with continuous stitches. Thorough toileting of the wound is followed by meticulous closure in layers over a suction drain. All patients were mobilised as soon as possible based on their neurological condition.

Neurological and functional outcomes of all patients were analysed with the ASIA scale (American Spine Injury Association impairment scale), Denis pain score and Denis work scale at the time of admission (preoperatively), postoperatively and at 9 months. Radiographic assessment for all patients with a preoperative radiograph and CT scan in the supine position measuring- Regional kyphotic angle at preoperative, postoperative and final follow-up. Figure 1 and 2 show postoperative xrays of patients with and without index screw.

Figure 1:  Postoperative X-ray showing screws in AP and lateral view shows without screw at fracture vertebrae.

Figure 2: Postoperative X- rays AP and Lateral view with index screw.

Results:

Of the total 108 patients- Group-A had 28 patients (10 prospective, 18 retrospective) without index screws in the fractured vertebra, Group-B had 80 patients (54 prospective, 26 retrospective) with index screw in the fractured vertebra. All the demographic details are summarised in Table and no significant difference was found between the 2 groups. Injury characteristics are summarised in Table- our majority of patients had fracture at dorsolumbar junction and no significant difference in the type of fracture or the neurological involvement but Group-B had a significantly low pre-operative kyphotic angle.

Demographic variableGroup-A (with index screw)Group-B (without index screw)P value
Age (years)- mean± SD (range)48.14±4.35 (26-78)44.88±12.89 (18-65)0.32
Gender- male/ female (%)19/9 (67.8/32.2)38/42 (47.5/52.5)0.063
Mode of injury- Fall/ Road traffic accident (%)27/1 (96.4/3.6)66/14 (82.5/17.5)0.18
Interval between admission and surgery- <5days>5days17/11 (60.7/39.3)58/22 (72.5/27.5)0.507

Table 1: Demographic details of patient population.

Injury characteristicGroup-A (with index screw)Group-B (without index screw)P value
Fracture vertebra level- Dorsal(D3-D8) Dorsolumbar(D9-L2), Lumbar(L3-L5)

11/15/2

(39.3%/53.6%/7.1%)

7/60/13

(8.8%/75%/16.2%)

<0>
AO classification- A/B/C28/0/0 (100%/0/0)77/2/1 (96.25%/2.5%/1.25%)0.77
Kyphotic angle29.39±6.8421.8±5.52<0>
TLICS score*5.04±0.515.26±0.710.122
ASIA score- A/B/C/D/E1/2/5/17/30/4/11/58/70.439

Table 2:  Preoperative injury characteristics of the patient population.

*Thoraco-Lumbar Injury Classification and Severity score.

Postoperatively, we found neurological improvement by 1 grade according to the ASIA scale but there was no significant difference between the two groups and significant improvement in kyphotic angle compared to preoperative value. These findings are summarised in Table 3.

Postoperative variableGroup-A (with index screw)Group-B (without index screw)P value
Kyphotic angle23.57±6.9516.41±5.21<0>
Change between preop-post op kyphotic angle5.82±1.825.38±2.390.23
ASIA score- A/B/C/D/E0/2/1/6/190/2/4/35/390.518

Table 3: Postoperative radiological and neurological outcomes.

Radiological and functional outcomes at 9 months follow-up are summarised in Table-4.

VariableGroup-A (with index screw)Group-B (without index screw)P value
Kyphotic angle25.39±7.0516.86±5.27<0>
Change between preop & final follow-up kyphotic angle4.0±1.614.93±2.710.12
Change between post op & final follow-up kyphotic angle1.82±1.700.45±1.90<0>
ASIA score- A/B/C/D/E0/1/1/4/220/2/3/8/670.919
Complications- Yes**/No26/2 (92.8/7.2)77/3 (96.2/3.8)0.345
Pedicle screw – intact/ broken25/3 (89.3/10.7%)79/1 (98.5/1.5%)0.053

Table 4: Outcomes evaluated at 9 months follow-up.

We found no significant difference in the neurological and functional outcomes (Denis scale as indicated in Table-5) but the change in kyphotic angle between the immediate postoperative period and 9 months follow-up was significantly less in group-B.

Denis scale (9months)Group A (n=28)Group B (n=80)p value
No.%No.% 
Pain
P11139.32227.50.24
P21450.05467.50.09
P3310.745.00.29
Work
W11242.82733.70.38
W21139.24252.50.22
W3310.7911.21.0
W427.322.50.26

Table 5: Denis’s scale assesment of functional outcome at 9 months.

P1- No pain, P2- Occasional, minimal pain without need for medication, P3- Moderate pain with occasional need for medication and no interruption of work or activities of daily living.

W1- return to previous employment (heavy labor) or physically demanding activities, W2- Able to return to previous employment (sedentary) or return to heavy labor with lifting restrictions, W3- Unable to return to previous employment but working full time at a new job, W4- unable to return to full time work.

Discussion:

In 1995 Bao Shan MD et al assessed the long-term results of short-segment pedicle instrumentation for burst fractures of thoracolumbar and lumbar spine. They found at least one-grade improvement in the Frenkel neurological grading system in 90.8% of patients with loss of correction of anterior vertebral body height and cobbs’ angle of 1.9% and 12.10 respectively at final follow-up and they recommended more adequate fusion given suboptimal results [6]. Conghui Zhang, Yang Liu did a clinical trial from Jan 1980 to July 2017 and concluded that combined pedicle screw fixation at the fracture vertebrae may be better than traditional fixation across the fracture level alone for thoracolumbar fractures [7]. In 2016 Kunpeng Li, MD et al in their meta-analysis suggested that the Combined screw fixation technique was seen with better reduction of the fractured vertebrae, less loss of correction in the follow-up, and lower rate of implant failure [8]

Dick et al and others [9][10][11][12] did in vitro biomechanical comparison evaluating the use of an intermediate screw on the pedicle at the fracture level, it showed that it could improve the stability of the pedicle screw fixation system and reduce the distribution of stress on each pedicle screw. In this study, the authors made an effort to compare the efficiency and safety of short-segment posterior spinal fixation for single-level thoracolumbar injury. We found no difference in the baseline demographic variables and injury characteristics other than significantly less kyphotic angle in group-B similar to the results found by lei wang et al and M.R. Farrokhi et al. [13][1] 

Postoperatively we found significant improvement in the kyphotic angle and ASIA score similar to available literature Khare S et al[14], Deng Z et al[15] with no significant difference in complication rates or implant failure similar to results of Zhang C et al (7)i.e, 0.63% implant failure in group A ( AFV - Adding fracture vertebrae) & 7.63% group B (CFV –cross fracture vertebrae). In our study we found that group-B patients had significantly less Change between post op & final follow-up kyphotic angle indicating that addition of index screw in the fractured vertebra helped in maintain the correction in the kyphotic angle better similar to results in the literature. (16)(6)(17). The functional outcomes measured by Denis scale were statistically similar in both groups.

Conclusion:

For thoracolumbar spine injuries if required operative management with short segment posterior spinal fixation is an acceptable treatment option as it will help in stabilisation and indirect decompression of the spinal cord by correcting the kyphotic collapse and help in early mobilisation of the patient. Addition of index screw in the fractured vertebra will help in better kyphosis correction, less correction loss in kyphotic angle in the follow up, in addition to fewer instrument failures, without additional complications.

References

Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

img

Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

img

Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

img

Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

img

Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

img

Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

img

Sing-yung Wu

Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.

img

Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

img

Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

img

Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

img

Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

img

Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

img

Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

img

Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

img

Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

img

Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

img

Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

img

Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

img

Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

img

Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

img

Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

img

Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

img

Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

img

Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

img

Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

img

S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

img

Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

img

George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

img

Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

img

Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

img

Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

img

Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

img

Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

img

Dr Maria Dolores Gomez Barriga

Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.

img

Dr Maria Regina Penchyna Nieto

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.

img

Dr Marcelo Flavio Gomes Jardim Filho

Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”

img

Zsuzsanna Bene

Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner

img

Dr Susan Weiner