Surgical timing, neurological recovery, and survival in spinal metastasis-induced paralysis: a retrospective cohort study with nomogram development

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Objective To investigate the association between surgical timing and neurological recovery and survival in patients with complete or incomplete paralysis due to metastatic spinal cord compression, and to develop a nomogram for predicting marked neurological recovery. Methods A total of 302 patients who underwent surgical decompression for spinal metastasis-induced paralysis between 2019 and 2023 were retrospectively analyzed. Patients were divided into four groups based on the time from paralysis onset to surgery: <24h, 24–72h, 72h–1w, and >1w. The primary outcome was marked neurological recovery (improvement to AIS D/E). Survival outcomes were also assessed. Multivariable Firth penalized logistic regression and Cox proportional hazards regression were performed. A nomogram was constructed and validated using bootstrap resampling (C-index, calibration curve, ROC curve, and decision curve analysis). Results Earlier surgery was strongly associated with better neurological recovery. Compared with the <24h group, the odds ratios for marked recovery were 0.69 (24–72h, p=0.361), 0.34 (72h–1w, p=0.019), and 0.17 (>1w, p<0.001). Delayed surgery was associated with significantly increased mortality risk: hazard ratios were 1.87 (72h–1w, p=0.026) and 4.44 (>1w, p<0.001). Preoperative AIS grade C (OR=6.86, p<0.001), higher ESCC grade (grade 2 vs. 1C: OR=0.14; grade 3 vs. 1C: OR=0.28), and flaccid muscle tone (OR=0.23, p<0.001) were independent predictors of recovery. The nomogram showed excellent discrimination with a bootstrap-corrected C-index of 0.873 and an AUC of 0.888 (95% CI: 0.852–0.925). Decision curve analysis confirmed its clinical utility. Conclusion Early surgery (within 1 week, ideally <24h) was associated with better neurological recovery and longer survival in patients with spinal metastasis-induced paralysis. However, given the retrospective design and the absence of key oncological covariates—including performance status, systemic disease burden, and visceral metastases—the survival association should be interpreted with caution and does not imply causality. Preoperative AIS grade C was associated with better recovery, while higher ESCC grade (grade 2 vs. 1C: OR=0.14; grade 3 vs. 1C: OR=0.28) was associated with lower odds of recovery, indicating that patients with less severe cord compression (ESCC grade 1C) had better outcomes. Flaccid muscle tone predicted poorer outcomes. The proposed nomogram provides a preliminary tool for individualized prediction of marked neurological recovery, pending external validation.

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