Comparative Validation of Scoring Systems in Acute Traumatic Central Cord Syndrome: Acute Traumatic Central Cord Syndrome Score,Central Cord Score,and Subaxial Cervical AO Spine Injury Score for Surgical Decision Making,Recovery,and Timing of Surgery

Abstract

Acute traumatic central cord syndrome (ATCCS) is the most common form of incomplete spinal cord injury. Treatment recommendations for ATCCS patients are largely from North America, and their applicability to Asian populations remains uncertain. Scoring systems such as the Acute Traumatic Central Cord Syndrome Score (ATCCSS), Central Cord Score (CCScore), and Subaxial Cervical AO Spine Injury Score (Subaxial AOSIS) can guide treatment, standardize practice, and improve outcomes. We aimed to validate and compare the predictive capabilities of ATCCSS, CCScore, and Subaxial AOSIS in a Southeast Asian population for surgical decision making, functional outcomes, and timing of surgery. We conducted a multicenter retrospective cohort study in Singapore from 2010 to 2023. The ATCCSS, CCScore, and Subaxial AOSIS were calculated for all patients and other relevant presenting, and radiological and surgical variables were collected. The primary outcome measure was significant motor recovery in the American Spinal Injury Association motor score (AMS) on 12-month follow-up. Secondary outcomes were significant motor recovery in the AMS score on 6-month follow-up, significant improvement in the Functional Independence Measure (FIM) score on 6-month follow-up, and significant recovery in the modified Japanese Orthopaedic Association (mJOA) score on 6-month follow-up. The predictive ability of the scores in predicting surgical management, meaningful recovery, and predicting timing of surgery was evaluated using receiver operating curve, with area under the curve (AUC) along with the corresponding 95% confidence intervals (CIs). Cutoff points were described for operative management and for the timing of surgery. A total of 116 patients were included with a mean age of 64.7 years (standard deviation = 12.9). The majority (86.2%) were male, and 65 (56.0%) patients underwent operative management. There was significant AMS improvement at 12 months in 95 (84.8%) of patients, significant AMS improvement at 6 months in 94 (83.2%) of patients, significant improvement in FIM at 6 months in 73 (62.9%) patients, and significant recovery in mJOA score in 67 (57.8%) of patients at 6 months. There were no significant differences in outcomes between operative and conservative management for functional outcomes. The median ATCCSS was 2 (interquartile range [IQR] 1), CCScore was 7 (IQR 4), and Subaxial AOSIS was 8 (IQR: 6). The ATCCSS had the highest predictive performance for the decision for operative management, with an AUC of 0.81 (95% CI: 0.73–0.89) compared with the other scores. All three scores did not predict motor and functional improvements well. The scores performed well for decision making in timing of surgery, with ATCCSS performing the best in predicting early surgery (AUC = 0.88, 95% CI: 0.81–0.95). The cutoff values for early surgery were 2.5 for ATCCSS and 8.5 for CCScore. Scoring systems in ATCCS performed well in decision making for surgery and timing of surgery but did not predict motor and functional recovery in a Southeast Asian cohort.

Graphical Abstract