Impact of delayed diagnosis on surgical management and neurological outcomes in elderly patients with cervical spinal cord injury without radiographic evidence of trauma: a multicenter registry study

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Abstract
Study design Multicenter retrospective cohort study. Objectives To investigate the impact of delayed diagnosis on treatment decisions and neurological outcomes in elderly patients with cervical spinal cord injury (CSCI) without radiographic evidence of trauma (SCIWORET). Setting Nationwide multicenter registry of the Japan Association of Spine Surgeons with Ambition (JASA). Methods Data from patients aged ≥65 years with traumatic cervical SCIWORET treated between 2010 and 2020 were reviewed. Delayed diagnosis was defined as a diagnosis of CSCI made more than 24 hours after injury, either because of (1) physician delay (missed diagnosis despite presentation) or (2) patient delay (injury-to-hospital arrival > 24 hours). Clinical characteristics, radiological findings, treatment strategies, and neurological outcomes (American Spinal Injury Association Impairment Scale, AIS) were compared between early and delayed diagnosis groups. Results Among 613 elderly patients with SCIWORET, 81 (12.8%) experienced delayed diagnosis. These patients were significantly older (p = 0.048), more frequently dependent for ambulation (p < 0.001), and commonly injured by ground-level falls (p < 0.01). Initial AIS grades and radiological findings were comparable between groups. However, patients with delayed diagnosis underwent more frequent surgical intervention at admission (p < 0.001) and more frequent conversion from conservative to surgical management due to neurological deterioration (p < 0.001). Final AIS grades did not differ significantly between groups. Conclusions Delayed diagnosis of SCIWORET in elderly patients is associated with increased surgical intervention without improved neurological recovery. Early recognition and timely MRI assessment may help reduce potentially avoidable surgery.

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