Clinical Outcomes After Traumatic Brain Injury and Exposure to Extracranial Surgery
Authors: Christopher J. Roberts, Jason Barber, Nancy R. Temkin, Athena Dong, Claudia S. Robertson, Alex B. Valadka, John K. Yue, Amy J. Markowitz, Geoffrey T. Manley, Lindsay D. Nelson, Neeraj Badjatia, Ramon Diaz-Arrastia, Ann-Christine Duhaime, V Ramana Feeser, Shankar Gopinath, Ramesh Grandhi, Ruchira Jha, C. Dirk Keene, Christopher Madden, Michael McCrea, Randall Merchant, Laura B. Ngwenya, Richard B Rodgers, David Schnyer, Sabrina R. Taylor, Ross Zafonte
Journal: JAMA Surgery (2023)

Importance Traumatic brain injury (TBI) is associated with persistent functional and cognitive deficits, which may be susceptible to secondary insults. The implications of exposure to surgery and anesthesia after TBI warrant investigation, given that surgery has been associated with neurocognitive disorders. Objective To examine whether exposure to extracranial (EC) surgery and anesthesia is related to worse functional and cognitive outcomes after TBI. Design, Setting, and Participants This study was a retrospective, secondary analysis of data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a prospective cohort study that assessed longitudinal outcomes of participants enrolled at 18 level I US trauma centers between February 1, 2014, and August 31, 2018. Participants were 17 years or older, presented within 24 hours of trauma, were admitted to an inpatient unit from the emergency department, had known Glasgow Coma Scale (GCS) and head computed tomography (CT) status, and did not undergo cranial surgery. This analysis was conducted between January 2, 2020, and August 8, 2023. Exposure Participants who underwent EC surgery during the index admission were compared with participants with no surgery in groups with a peripheral orthopedic injury or a TBI and were classified as having uncomplicated mild TBI (GCS score of 13-15 and negative CT results [CT − mTBI]), complicated mild TBI (GCS score of 13-15 and positive CT results [CT + mTBI]), or moderate to severe TBI (GCS score of 3-12 [m/sTBI]). Main Outcomes and Measures The primary outcomes were functional limitations quantified by the Glasgow Outcome Scale–Extended for all injuries (GOSE-ALL) and brain injury (GOSE-TBI) and neurocognitive outcomes at 2 weeks and 6 months after injury. Results A total of 1835 participants (mean [SD] age, 42.2 [17.8] years; 1279 [70%] male; 299 Black, 1412 White, and 96 other) were analyzed, including 1349 nonsurgical participants and 486 participants undergoing EC surgery. The participants undergoing EC surgery across all TBI severities had significantly worse GOSE-ALL scores at 2 weeks and 6 months compared with their nonsurgical counterparts. At 6 months after injury, m/sTBI and CT + mTBI participants who underwent EC surgery had significantly worse GOSE-TBI scores (B = −1.11 [95% CI, −1.53 to −0.68] in participants with m/sTBI and −0.39 [95% CI, −0.77 to −0.01] in participants with CT + mTBI) and performed worse on the Trail Making Test Part B (B = 30.1 [95% CI, 11.9-48.2] in participants with m/sTBI and 26.3 [95% CI, 11.3-41.2] in participants with CT + mTBI). Conclusions and Relevance This study found that exposure to EC surgery and anesthesia was associated with adverse functional outcomes and impaired executive function after TBI. This unfavorable association warrants further investigation of the potential mechanisms and clinical implications that could inform decisions regarding the timing of surgical interventions in patients after TBI.