Original Investigation
Critical Care Medicine
One-Year Outcomes After Traumatic Brain Injury and Early Extracranial Surgery in the TRACK-TBI Study
Christopher J. Roberts, Amelia W. Maiga, Jason Barber, et al
JAMA Netw Open 2025;8;(10):e2537271. doi:10.1001/jamanetworkopen.2025.37271
Question Are traumatic brain injury (TBI) outcomes at 1 year worse in individuals exposed to extracranial surgery early after trauma compared with people unexposed?
Findings In this multicenter cohort study of 1150 participants that had follow-up at 1 year, participants undergoing extracranial surgery early after TBI and those with acute intracranial findings on computed tomography had worse functional, cognitive, and disability outcomes compared with general orthopedic trauma patients or those with TBI with imaging negative for acute intracranial findings.
Meaning The results suggest that for patients with TBI-induced radiographic abnormalities, early extracranial surgery may generate additional neurotoxic mediators that act as secondary insults to an already injured brain.
Abstract
Importance Exposure to extracranial (EC) surgery early after traumatic brain injury (TBI) is associated with cognitive risks.
Objective To examine whether exposure to EC surgery during a TBI index admission is associated with worse outcomes at 1 year compared with no EC surgery.
Design, Setting, and Participants This was a retrospective secondary nested cohort study of the prospective, observational Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) cohort study that enrolled participants from February 1, 2014, through August 31, 2018, at 18 US level I trauma centers. Participants aged 17 years or older who were admitted to an inpatient unit from the emergency department (ED) within 24 hours of trauma, had a known Glasgow Coma Scale (GCS) score and head computed tomography (CT) imaging, and did not undergo intracranial surgery were followed for up to 1 year after TBI and were analyzed for this study from July 25, 2023, to July 2, 2025.
Exposure Participants that underwent EC surgery during the index admission were compared with nonsurgical participants within the following injury subgroups: orthopedic trauma controls (OTCs), moderate-severe TBI (GCS 3-12), and computed tomography (CT) scan results that were positive (CT+) or negative (CT−) for acute intracranial findings along with a GCS score of 13 to 15.
Main Outcomes and Measures Brain injury–specific functional outcomes (Glasgow Outcome Scale–Extended [GOSE-TBI]), cognition (Trail Making Test [Trails] parts A and B), Disability Rating Scale (DRS), and Quality of Life After Brain Injury–Overall Scale (QOLIBRI-OS). A fixed-effects linear regression model with propensity weighting for missing outcome and group imbalance in baseline characteristics was used.
Results Of the 1835 participants, 1279 (70%) were male, with mean (SD) age of 42.2 (17.8) years; 1349 participants (74%) were nonsurgical and 486 (26%) underwent EC surgery. In the 1150 participants (63%) followed up at 1 year, after propensity weighting, patients undergoing EC surgery in both the CT+ TBI and moderate-severe TBI subgroups had significantly worse GOSE-TBI (B, −0.57 [95% CI, −0.92 to −0.22] and −1.25 [95% CI, −1.65 to −0.85], respectively), Trails part B (B, 22.7 [95% CI, 7.4-38.1] and 47.9 [95% CI, 27.0-68.8]), and DRS (B, 2.47 [95% CI, 1.30-3.64] and 3.53 [95% CI, 2.19-4.87]) scores compared with nonsurgical participants. QOLIBRI-OS was worse after EC surgery vs no EC surgery in the subgroup with moderate-severe TBI (B, −15.1 [95% CI, −24.3 to −5.9]). There was no association of EC surgery with outcomes in the OTC or CT− TBI subgroups. For example, GOSE-TBI was not associated with EC surgery in the CT− TBI subgroup (B, 0.02 [95% CI, −0.24 to 0.27]).
Conclusions and Relevance In this cohort study, early EC surgery was associated with adverse function, cognition, and disability after TBI rated as moderate-severe or with radiographic abnormalities on CT scan regardless of GCS at index admission but not after orthopedic trauma or CT− TBI. Further studies may help determine whether surgical timing or other interventions can improve the observed long-term deficits.
