-->PONE-D-26-09186-->-->Prognostic Significance of Nutritional Status for Neurological and Functional Recovery after Cervical Spinal Cord Injury-->-->PLOS One

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Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Manuscript Title: Prognostic Significance of Nutritional Status for Neurological and Functional Recovery after Cervical Spinal Cord Injury

Strengths

This study addresses a clinically relevant question by examining the association between early nutritional status and recovery after cervical SCI. The use of validated nutritional indices alongside standardized neurological and functional outcomes strengthens the analysis, and the focus on the early post-injury period enhances its clinical relevance. The identification of PNI as an independent predictor of recovery is particularly noteworthy and supports the potential role of nutritional assessment in early prognostic evaluation.

Weaknesses and Recommendations

Several aspects of the study would benefit from further clarification and refinement. There is some inconsistency in the terminology used to describe neurological outcomes (e.g., ASIA motor score, AIS, ISNCSCI), and clearer specification of the measures applied would enhance interpretability. Additional methodological detail would also strengthen the manuscript, particularly regarding the clinical context at 4 weeks (e.g., rehabilitation setting, standard nutritional support) and the definition of certain exclusion criteria such as “systemic deterioration.” The presentation of results could be streamlined to improve clarity and flow, with more consistent reporting of ranges and outcomes. While the inclusion of multiple nutritional indices is a strength, the use of BMI would benefit from acknowledgment of its known limitations in the SCI population, where it may not accurately reflect body composition or cardiometabolic risk. Finally, minor refinements in the conclusions and table organization could further improve overall readability.

Specific Comments:

Abstract:

It is mentioned that: “Neurological function was assessed using the American Spinal Injury Association (ASIA) motor score”….were only the motor scores used?? Or you meant the ASIA Impairment Scale (AIS)??

Methods:

Could you please explain more, what do you mean by: “…..and 14 due to systemic deterioration.”

Line 78-79: “Neurological status was assessed using the American Spinal Injury Association 79 (ASIA) motor score..” do you mean ASIA impairment scale (AIS)? Or the international standards for neurological classification of spinal cord injury (ISNCSCI).

Line 82-83: I suggest using this language for AIS C definition “less than half of key muscle functions below the single NLI have a muscle grade ≥ 3.”

Line 98: “the CONUT score, an indicator of nutritional and immunological status,”….in the intro it is mentioned that CONUT score captures both protein and energy deficiency. Please clarify.

Line 106: “ASIA motor score” please change to ISNCSCI motor scores” (and modify everywhere where it is applicable)…..Consider using also the terminology of “Total motor scores (TMS) or Upper extremity motor scores (UEMS)”, depending on which motor scores you are using.;

Periods (.) are missing after “100” in line 111 and line 114.

Please elaborate as part of the methods, is the patients at 4 weeks were receiving inpatient acute rehab or outpatient. If as part of the regular treatment they receive any nutritional support?? Or what is the standard protocol regarding nutrition and you institution.

Results:

Line 148-150: with this statement I am assuming you used total motor scores, but it’s until now that I realize this. Please specify form the beginning and adjust accordingly.

If you used SCIM III version, please specify from the very beginning.

Line 153-155: Please check that the ranges in parentheses are correct: “The mean change in 154 SCIM score was 21.6 ± 18.22 (range, −2 – 80), with a mean SCIM recovery rate of 27.96 ± 155 24.84% (range, −2.38% – 95.74%) (Table 1)”

Line 161-168: I suggest adding all the percentages.

The paragraph on “Nutritional status at 4 weeks and 6 months after SCI”….is a bit confusing, try to present the results in order for pre and post by each outcome measure, other wise the reader has to move up and down to see the pre and post values.

The “Multivariable linear regression analyses for neurological and functional recovery” paragraph is a bit hard to follow; please consider re-ordering the information and avoiding repetition.

Conclusions:

This sentence in conclusions: “Although nutritional status was not an independent predictor of functional recovery assessed by SCI after multivariable adjustment, its significant associations with neurological improvement suggest that nutritional status may influence functional recovery indirectly through its effects on neurological recovery.” Belongs to the discussion, I don’t think this is a conclusion

Tables:

Could table 4 and 5 be condensed in one table?

Reviewer #2: Congratulations.

A very interesting cohort study correlating nutritional status with cervical spinal cord injury.

I have a question: among the patients included in this clinical research, were there any subject with a metabolic or endocrine disorder?

It would also be interesting to continue this type of study and include nutritional management during the follow-up period as a controlled variable.

Reviewer #3: In this retrospective study, the authors investigated the prognostic value of early nutritional indices - the Prognostic Nutritional Index (PNI), Geriatric Nutritional Risk Index (GNRI), and Controlling Nutritional Status (CONUT) score - in predicting recovery outcomes for patients with traumatic cervical spinal cord injury (SCI). The study highlights a modifiable factor in rehabilitation of patients with cervical spinal cord injury. The authors have utilized appropriate multivariate liner regression tools to control for confounders. The manuscript is well-structured, and the results have been compiled appropriately. However, the following major and minor flaws remain that need to be addressed:

1. Methods: Please explain how 4 weeks post injury time interval was selected as “early nutritional status” in this study vs. on admission? Is this a standard timeline for determining early nutritional status in spinal cord injury patients? Discuss the rationale for selecting this cut off in the methods.

2. What was the mean length of stay for 206 eligible patients?

3. The study started with 206 eligible patients but excluded 94 due to early discharge/transfer. The authors must address whether the "early discharge" group differed significantly from the "included" group. If the healthier patients were discharged early, the remaining cohort might be skewed toward more severe cases, biasing the results.

4. Serum albumin is a negative acute phase reactant in critically ill patients and hence may influence PNI. A low PNI may simply be a proxy for a high "complication burden" (pneumonia, UTI) rather than nutritional intake itself. Please discuss under limitations of using PNI as a nutritional index.

5. The study did not mention the type of nutritional support received (TPN, enteral, or oral) during the first few weeks post injury. Differences in feeds and mode of providing nutrition could be a significant confounding variable that influences both the PNI and the recovery rate. Please address this under Discussion.

6. In the Results (Line 162), the PNI categories are listed as "good, normal, and poor," while the Methods (Line 90) use "normal, mild, and moderate to severe." Please check and make necessary corrections to ensure consistency throughout the manuscript including tables.

7. Due to retrospective nature of the study, poor nutritional status as a cause for poor neurological recovery cannot be determined. Low PNI may represent an inflammatory state especially in patients with complications (pneumonia, pressure ulcers, etc.) post injury. The conclusions should explicitly suggest that PNI may be a useful prognostic marker for neurological and functional recovery.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Prognostic Significance of Nutritional Status for Neurological and Functional Recovery after Cervical Spinal Cord Injury

PONE-D-26-09186R1

Dear Dr. Yokota,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Zubing Mei, MD,Ph.D

Academic Editor

PLOS One

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Reviewer #3: All comments have been addressed

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-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #3: Yes

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-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #3: Yes

**********

-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #3: Yes

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-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #3: Yes

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-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #3: (No Response)

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Reviewer #3: No

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