Development Of A Nomogram Model For Predicting Tracheostomy In Traumatic Cervical Spinal Cord Injury And Analysis Of Risk Factors On Tracheostomy

Objective:Part one:To develop a nomogram for the prediction of tracheostomy in patients with traumatic cervical spinal cord injury(TCSCI).Part two:To investigate the continuous relationship between age and tracheostomy in patients with TCSCI.Part three:Early prediction of tracheostomy in TCSCI patients is often difficult.This part aims to clarify the association between shoulder abductor strength(SAS)and tracheostomy in patients with TCSCI.Methods:Part one:A total of 689 patients with TCSCI admitted to our hospital from January 2008 to December 2021 were included in this study part.First,the variable selection was performed using between-group comparisons and LASSO regression analysis.Second,a multivariate logistic regression analysis(MLRA)with a step-by-step method was performed.A nomogram model was developed based on the MLRA.Finally,the model was validated by receiver operating characteristic(ROC)curve analysis,calibration curve analysis and decision curve analysis(DCA)on the training group and validation group.Part two:A total of 689 patients with TCSCI admitted to our hospital from January 2008 to December 2021 were included in this study part.The logistic regression and restricted cubic spline(RCS)analysis was applied to analyze the possible dose-response relationship between age and tracheostomy.The subgroup analysis was performed for the American Spinal Injury Association(ASIA)grade and neurological level of injury(NLI).Part three:Five hundred thirteen TCSCI patients treated at our institution from October 2010 to October 2020 were retrospectively analyzed.All patients were divided into a tracheostomy group and a non-tracheostomy group.The SAS was assessed at admission using the Medical Research Council(MRC)Scale for Muscle Strength grading.Potential predictors including age,gender,smoking history,SAS,ASIA grade and NLI were assessed for their association with tracheostomy in patients.A nomogram was developed based on MLRA to visualize the predictive ability of the SAS.Validation of the nomogram was performed to judge whether the nomogram was reliable for visual analysis of the SAS.Receiver operating characteristics curve,specificity,and sensitivity were also performed to assess the predictive ability of the SAS.Results:Part one:The nomogram prediction model incorporated 5 predictors,including smoking history,dislocation,thoracic injury,ASIA grade,and NLI.The Area Under Curve(AUC)in the training group and in the validation group were 0.883 and 0.909,respectively.The HosmerLemeshow test result was p = 0.153.The DCA demonstrated a higher net benefit of nomogram-assisted decisions compared to tracheostomy of all patients or none.The model performed well and was feasible to make beneficial clinical decisions.Part two:The proportion of patients with the age≥60 was significantly higher in the tracheostomy group than in the non-tracheostomy group(41.2% vs.26.7%,p = 0.003).Age ≥ 60 was independently associated with tracheostomy(total: OR = 3.560,95% CI: 1.892-6.697,P <0.001)after adjusting for gender,smoking history,dislocation,respiratory complications,ASIA grade,NLI,preexisting lung disease,brain injury,and thoracic injury.After the relationship was present in the subgroup analysis,the RCS revealed a nonlinear relationship between age and tracheostomy(P-overall < 0.001,P-nonlinear = 0.021).Part three:The proportion of patients with the SAS grade 0–2 was significantly higher in the tracheostomy group than in the non-tracheostomy group(88.1% vs.54.8%,p = 0.001).The SAS grade 0–2 was identified as a significant predictor of the tracheostomy(OR: 4.505;95%CI: 2.080-9.758;p=0.001).Points corresponding to both the SAS grade 0–2 and the neurological level of injury at C2-C4 were between 60 and 70 in the nomogram.The area under the curve for the SAS grade 0–2 was 0.692.The sensitivity of SAS grade 0-2 was0.239.The specificity of SAS grade 0-2 was 0.951.Conclusions:Part one:The nomogram combining dislocation,thoracic injury,ASIA grade A,NLI,and smoking history was validated as a reliable model for the prediction of tracheostomy.Part two:Age and tracheostomy present a dose-response relationship in patients with TCSCI.This finding could help physicians bring assistance in the early identification of tracheostomy and rationalize the allocation of medical resources.Part three:SAS is a novel predictor of tracheostomy in patients after TCSCI.The SAS grade 0–2had a good predictive ability of tracheostomy.