The SCARE Score: A Simplified Risk Score for Predicting Intraoperative Neuromonitoring Signal Loss in Pediatric...

Neurological injury remains one of the most serious complications during pediatric spinal deformity surgery. Intraoperative neuromonitoring (IONM) techniques applied to mitigate the risk of iatrogenic neurological injury allow real-time assessment of the patient's neurological status. The purpose of this study was to determine which preoperative parameters are associated with IONM signal loss in pediatric spinal deformity surgery, with a view toward constructing an easy-to-use yet statistically robust risk-assessment score. The score should allow surgeons to predict which patients have increased odds of IONM signal loss.

We conducted a retrospective analysis of prospectively collected data from a tertiary pediatric spinal deformity center, including 413 spinal deformity surgeries in 360 patients between 2020 and 2024. The extracted preoperative demographic data underwent univariate and multivariable analysis. Regression coefficients were then employed to construct a simplified clinical risk score, in which each independent predictor was assigned a weighted point value. Significance was defined as p < 0.05. Internal validation was performed with a 70/30 training/testing split and tenfold cross-validation.

Neuromonitoring signal loss occurred in 24% of patients. Following univariate and multivariable analysis, the final parsimonious SCARE model included Spinal Cord morphology, deformity Angular ratio, Revision surgery, and syndromic Etiology as independent predictors. Total risk scores range from 0 to 12 points and low risk was considered 0 to 5 points; moderate risk, 6 to 8 points, and high risk, ≥9 points. Observed IONM event rates in these groups were 3.3% to 14.1%, 18.4% to 29.7%, and 36.6% to 59.7%, respectively. The point-based risk score achieved an area under the receiver operating characteristic curve of ≈0.74 on the testing data.

The SCARE score is a predictive, internally validated, simple, and memorizable preoperative tool for estimating the IONM signal loss risk in pediatric spinal deformity surgery. While further external validation is essential, we hope that it will aid surgical planning, inform perioperative discussions, and contribute to safer management of children with spinal deformities.

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.