Highlight
1. Early extracranial (EC) surgery after traumatic brain injury (TBI) is associated with worsened functional and cognitive outcomes at 1 year, particularly in patients with moderate-severe TBI or positive brain CT scan findings.
2. No significant outcome differences were observed in patients with orthopedic trauma or TBI with negative CT scans undergoing EC surgery.
3. The findings underscore the need for further research on optimizing surgical timing and perioperative care for TBI patients undergoing extracranial interventions.
Background
Traumatic brain injury (TBI) is a major global health burden, contributing to substantial morbidity, mortality, and long-term disability. Management often involves a critical focus on preventing secondary brain injury and optimizing neurological recovery. However, patients who sustain polytrauma frequently require extracranial (EC) surgeries early after injury. While such surgeries address urgent non-neurological injuries, their impact on brain recovery and long-term neurologic outcomes has been understudied.
Cognitive deficits, functional impairments, and reduced quality of life are common sequelae of moderate to severe TBI. Understanding how interventions outside the brain, such as EC surgeries, affect these outcomes is vital to guiding treatment strategies in this complex patient population. The TRACK-TBI cohort offers a unique opportunity to evaluate these associations systematically across multiple trauma centers.
Study Design
This investigation was a retrospective secondary nested cohort study drawing from the prospective TRACK-TBI project, involving 18 US level I trauma centers. Participants aged 17 years or older who were admitted within 24 hours of injury, with documented Glasgow Coma Scale (GCS) scores and head CT imaging, were included. Notably, participants who underwent intracranial surgery were excluded to isolate the effects of extracranial surgical interventions.
Participants were stratified based on injury severity and CT findings into subgroups:
– Orthopedic Trauma Controls (OTCs)
– Moderate-Severe TBI (GCS 3-12)
– Mild TBI with Positive CT findings (CT+ and GCS 13-15)
– Mild TBI with Negative CT findings (CT- and GCS 13-15)
The exposure of interest was undergoing any EC surgery during the index hospital admission. Outcomes assessed at one year included:
– Glasgow Outcome Scale-Extended specific to TBI (GOSE-TBI)
– Cognitive function via Trail Making Tests parts A and B (Trails A and B)
– Disability Rating Scale (DRS)
– Quality of Life After Brain Injury-Overall Scale (QOLIBRI-OS)
Statistical analyses employed fixed-effects linear regression with propensity weighting to adjust for baseline imbalances and missing data.
Key Findings
The study analyzed 1835 participants (mean age 42.2 years, 70% male), of whom 486 (26%) underwent early EC surgery. Follow-up data were available for 1150 patients at one year.
Among patients with moderate-severe TBI or positive CT scans, those who had EC surgery demonstrated significantly poorer outcomes:
– GOSE-TBI scores were reduced (moderate-severe TBI: B = -1.25; CT+ TBI: B = -0.57), signifying worse global functional recovery.
– Cognitive performance on Trails part B was notably impaired (moderate-severe TBI: B = 47.9 seconds more to complete; CT+ TBI: B = 22.7 seconds), indicating executive function deficits.
– DRS scores indicating disability were higher (moderate-severe TBI: B = 3.53; CT+ TBI: B = 2.47), marking increased disability.
– Quality of life as measured by QOLIBRI-OS was significantly diminished in moderate-severe TBI patients (B = -15.1).
Conversely, patients with orthopedic trauma alone or those with mild TBI and negative CT scans did not exhibit significant differences in outcomes related to EC surgery exposure.
These results persisted after adjusting for confounding variables, supporting an independent association between early EC surgery and adverse neurological outcomes in moderate-severe or radiographically positive TBI.
Expert Commentary
The findings raise important clinical considerations regarding the timing and coordination of extracranial surgical interventions in TBI patients. While necessary for life or limb-threatening conditions, EC surgeries may contribute to systemic inflammatory responses, hemodynamic instability, or metabolic demands that exacerbate brain injury or impede recovery. The worse cognitive and functional outcomes seen may reflect these complex pathophysiological interactions.
Limitations of the study include its observational design, which cannot establish causality definitively, and potential residual confounding despite propensity adjustments. Additionally, heterogeneity in the types and urgency of EC surgeries may influence outcomes differently but were not separately analyzed.
Future research should focus on mechanistic studies to elucidate the biological basis for these associations and controlled trials evaluating optimal timing and perioperative management strategies for EC surgeries in TBI patients.
Conclusion
This robust multicenter cohort study demonstrates that early extracranial surgery during the index admission for traumatic brain injury is associated with significantly worse one-year cognitive, functional, and disability outcomes in patients with moderate-severe injury or positive intracranial CT findings. These effects were not observed in mild TBI patients with negative imaging or in patients with isolated orthopedic injuries.
Clinicians managing polytrauma patients with TBI should carefully weigh the timing and necessity of extracranial surgeries and consider strategies to mitigate potential risks to brain recovery. The study highlights an important area of clinical research with potential to inform guidelines and improve long-term outcomes for this vulnerable population.
Funding and ClinicalTrials.gov Registration
The TRACK-TBI study was funded by the Department of Defense and the National Institutes of Health. The clinical trial is registered at ClinicalTrials.gov (NCT01565551).
References
- Roberts CJ, Maiga AW, Barber J, et al. One-Year Outcomes After Traumatic Brain Injury and Early Extracranial Surgery in the TRACK-TBI Study. JAMA Netw Open. 2025;8(10):e2537271. doi:10.1001/jamanetworkopen.2025.37271
- Maas AIR, Menon DK, Adelson PD, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017;16(12):987-1048. doi:10.1016/S1474-4422(17)30371-X
- Stein SC, Georgoff P, Meghan S, et al. Mild traumatic brain injury: a risk factor for neurodegenerative disease. J Neurosurg. 2015;122(4):877-885. doi:10.3171/2014.11.JNS14770
- Diaz-Arrastia R, Kochanek PM, Bergold P, et al. Pharmacology and therapeutics for traumatic brain injury. Handb Clin Neurol. 2015;127:229-256. doi:10.1016/B978-0-444-52892-6.00013-2
