Development and validation of a nomogram for predicting tracheostomy risk in traumatic cervical spinal cord injury

Tracheostomy is common in traumatic cervical spinal cord injury (TCSCI) because of respiratory complications, yet objective tools to estimate individual risk remain limited.

In this single-center retrospective cohort at the Second Affiliated Hospital, Zhejiang University School of Medicine, we enrolled 308 consecutive ICU admissions with TCSCI (January 2018-March 2023) and randomly split the cohort 7:3 (outcome-stratified) into training (n = 215) and validation (n = 93) sets. Candidate admission predictors were screened with Least Absolute Shrinkage and Selection Operator and then entered into multivariable logistic regression to construct a nomogram. Model performance included discrimination (AUC with bootstrap 95% CIs, 2,000 resamples), calibration (intercept, slope, Brier), and decision curve analysis (DCA). A prespecified clinical threshold of 0.30 was used to summarize sensitivity and specificity.

Five independent predictors were retained-smoking history, thoracic injury, BMI ≥ 25 kg/m², cervical dislocation, and ASIA grade (A vs. B-D). The model showed strong discrimination (AUC 0.844, 95% CI 0.788-0.896 in training; 0.903, 95% CI 0.823-0.966 in validation) and good calibration. At the 0.30 threshold, performance was Sensitivity 0.781/Specificity 0.725 (training) and Sensitivity 0.812/Specificity 0.852 (validation); DCA demonstrated greater net benefit than "treat all/none" across threshold 0.10-0.70.

A parsimonious, five-factor nomogram based on routine admission data provides accurate, clinically interpretable stratification of tracheostomy risk in TCSCI. Clear reporting of ASIA coding and a prespecified decision threshold enhance bedside usability. Prospective, multi-center external validation is warranted.