Invited Commentary
December 13, 2023
Surgery, Anesthesia, and TBI Outcomes—Unraveling the Complex Interplay
Caitlin R. Collins, Andre Campbell
JAMA Surg. Published online December 13, 2023. doi:10.1001/jamasurg.2023.6371
In their study “Extracranial Surgery and Functional and Cognitive Outcomes After Traumatic Brain Injury: A TRACK-TBI Study,”1 Roberts et al shed crucial light on the potential risks associated with extracranial surgery in patients with traumatic brain injury (TBI). Their research provides a necessary foundation for a more informed risk-benefit analysis regarding surgery in these patients. While the majority of extracranial operations studied were related to the traumatic injury (and therefore likely urgent and necessary), we agree that TBI should be explicitly highlighted as a nonmodifiable risk factor for postoperative neurocognitive disorders during informed consent discussions. Additionally, delaying any nonurgent surgical intervention for patients with moderate to severe TBI or for patients with mild TBI and positive results of computed tomography of the head should be strongly considered.
One area warranting further examination remains the potential influence of anesthetic techniques on postoperative outcomes for patients with TBI. Although Roberts et al1 reference prior studies2-4 indicating no significant difference in postoperative neurocognitive disorders based on anesthetic technique, it is important to note that many of these studies focused on older populations undergoing a heterogeneous array of procedures. Because most patients with trauma are young and have fewer preexisting medical comorbidities than most studied surgical populations, they represent a distinct population worth individual evaluation. These prior studies2-4 also often compared general anesthesia vs epidural anesthesia, which can produce similar, detrimental hemodynamic changes. Because many of the extracranial operations were for extremity fractures, peripheral nerve blocks may represent a more appealing comparison with general anesthesia given their more limited associations with hemodynamic parameters.
Future attempts to clarify the interplay between surgery or anesthesia and neurocognitive outcomes in patients with TBI should include both full neuropsychological testing to further delineate the cognitive impact and intraoperative data. Hypotension and hypoxemia are well-established secondary insults that result in worsened neurologic outcomes. These vital signs are also closely monitored intraoperatively and are typically captured in the electronic medical record. It is crucial to consider their potential impact on the observed outcomes. Further analyses should aim to control for prolonged episodes of intraoperative hypotension or hypoxemia to minimize the potential for conflating surgery or anesthesia with previously well-described harms in patients with TBI.
Roberts et al1 masterfully elucidate the nuanced interplay between surgery, anesthesia, and TBI. While the avenues for further inquiry and elucidation remain vast, this study lays the groundwork for further investigation, offering a platform for refining and optimizing the care of patients with TBI undergoing extracranial surgery.
