J.C. Wang replies:
I would like to comment on the concern that the references in our study may have been misquoted in regard to the treatment of patients with lumbar disc herniations and low back pain.
This particular section of the manuscript begins with the clear statement that when the numerous studies in the literature are reviewed, there may be confusion because "grouping patients with the diagnosis, or with symptoms of low back pain, mixes patients with multiple potential pain generators." Also, it states that "in a review of the literature, many studies examining the results of spine surgery had a heterogeneous group of patients with different primary diagnoses who may also have had other associated symptoms in addition to low back pain." The article proceeds to document studies in which patients had defined diagnoses other than just low back pain and degenerative disc disease, and it discusses the element of low back pain with the diagnosis of spondylolisthesis, lumbar disc herniations, and kyphosis and/or scoliosis, in which the res2ults of the treatment are better than those for patients with undefined low back pain. In this context, the references are meant to show that symptoms of low back pain that are coexistent with the defined pathologies of spondylolisthesis, lumbar disc herniations, and deformities have a more favorable prognosis. The reference in question was intended in this context to illustrate the symptoms of low back pain associated with the herniated disc diagnosis. The last part of this section of the article deals with unspecified low back pain associated with only degenerative disc disease, and these references are not used to support disc surgery for the treatment of this entity.
I thank the author of the letter for clarifying the point that this reference deals only with patients with lumbar disc herniations and is not meant to justify lumbar disc excision for primary low back symptoms. This is a critical point and this point must be clear.