Extracranial Surgery, Anesthesia After TBI Tied to Poorer Clinical Outcomes

Extracranial surgery and anesthesia are associated with impaired functional and executive outcomes post-traumatic brain injury (TBI), according to study findings published in JAMA Surgery.

Nearly half of patients with TBI require surgical intervention. However, evidence suggests that surgery and anesthesia are harmful to the brain. 

Researchers conducted a retrospective, secondary analysis to evaluate if extracranial surgery and anesthesia are associated with worsened cognition and function after TBI. The definition of extracranial surgery is all surgical operations conducted outside of the skull and intracranial vault. 

The researchers analyzed data from Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK- TBI), a prospective, observational, cohort study. Study participants were recruited from 18 level I US trauma centers who presented within 24 hours of TBI with a head computerized tomography (CT) scan.

Scans were characterized based on the National Institute of Neurological Disorders and Stroke (NINDS) Common Data Element Neuroimaging Working Group consensus recommendations. 

Patients who were incarcerated, pregnant, or who did not speak English or Spanish were not included in the study. Other exclusion criteria were nonsurvivable physical trauma, debilitating mental health disorders, and neurologic diseases.

The primary outcomes were functional limitations defined 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. The Trail Making Test Parts A and B was used to assess neurocognitive outcomes among other tests. 

Participants were classified based on the Glasgow Coma Scale (GCS) score: uncomplicated mild TBI (GCS score of 13-15 and negative CT results, complicated mild TBI (GCS score of 13-15 and positive CT results, or moderate to severe TBI (GCS score of 3-12).

Of the 2996 participants in the initial cohort, 1835 (mean age, 42.2; 70% men) participants were included in the final analysis, with 1349 nonsurgical participants and 486 participants undergoing extracranial surgery. In this study, 89% of participants were discharged by week 2 after TBI. 

Compared with other groups at both time points, patients with moderate to severe TBI had worse outcomes on GOSE-TBI and GOSE-ALL.

At both 2 weeks and 6 months, compared to patients who did not require surgery, those undergoing extracranial surgery with all TBI severities had significantly worse GOSE-ALL scores.

Participants with moderate to severe TBI (B, -1.11; 95% CI, -1.53 to -0.68) and mild TBI and positive CT results (B, -0.39; 95% CI, -0.77 to -0.01) who underwent surgery had worse GOSE-TBI scores at 6 months after injury.

Compared with other groups, individuals with moderate to severe TBI (B, 30.1; 95% CI, 11.9-48.2) and mild TBI and positive CT results (B, 26.3; 95% CI, 11.3-41.2) had significantly worse scores on the Trail Making Test Part B.

Study limitations are confounding based on the indication and severity of TBI, the potential for covariates to influence results, the inclusion of participants whose only surgeries were a tracheostomy or gastrostomy tube, and differences in presenting shock index.

“TBI might need to be included in the list of nonmodifiable patient factors, along with age and preclinical or diagnosed dementia, that increase the risk for postoperative neurocognitive disorders,” the researchers concluded.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.