Extracranial (EC) surgery and anesthesia soon after a traumatic brain injury (TBI) are associated with poorer functional and cognitive outcomes, new research shows.
Patients with TBI had worse functional recovery and poorer neurocognitive outcomes across all TBI severities at 2 weeks and 6 months compared with their counterparts who did not undergo surgery.
Those with moderate to severe TBI (m/sTBI) and those with complicated mild TBI and positive results on CT (CT+ mTBI) reported the worst outcomes.
"These findings support the hypothesis that surgery and anesthesia, or alternatively multiple trauma, might need to be included in the list of secondary insults to be avoided, if possible, to protect the brain after TBI," lead investigator, Christopher J. Roberts, MD, PhD, from the Department of Anesthesiology at the Medical College of Wisconsin and at Zablocki Veterans Affairs Medical Center, Milwaukee, and coauthors write.
The findings were published online December 13 in JAMA Surgery.
Impact on Recovery
For the retrospective study, investigators examined data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury study, a prospective cohort longitudinal study conducted at 18 Level I US trauma centers between 2014 and 2018.
The study included 1835 patients (mean age, 42 years; 70% male) in this secondary analysis, all of whom were seen within 24 hours of the TBI and had had no cranial surgery for TBI at baseline.
EC surgery was performed on 486 patients during the study period, mostly for extremity fracture.
Functional recovery from TBI was measured with the Glasgow Outcome Scale–Extended for all injuries (GOSE-ALL) and specifically for brain injury (GOSE-TBI). Neurocognitive outcomes were measured with the Trail Making Test Parts A and B.
Those who underwent EC surgery had significantly worse functional recovery and neurocognitive outcomes at 2 weeks and 6 months compared with the nonsurgical group, regardless of TBI severity. The worst outcomes were found in patients with m/sTBI (P <.001) and CT+ mTBI (P =.001) at 6 months.
"Most strikingly, in both the m/sTBI and CT+ mTBI groups, the effect of EC surgery at 6 months was comparable for GOSE-ALL and GOSE-TBI scores, suggesting that EC surgery may impact brain recovery after TBI," the authors write.
Delaying Nonurgent Surgery
In an accompanying editorial, Caitlin R. Collins, MD, MPH, and Andre Campbell, MD, both of the Department of Surgery, School of Medicine, University of California, San Francisco, write that the study "provides a necessary foundation for a more informed risk-benefit analysis regarding surgery in these patients."
Research suggests about 50% of patients with mild TBI undergo surgery within 1 week of their injury and 5% have procedures or surgeries unrelated to the trauma that caused their TBI.
Although most EC surgeries included in the study were related to the traumatic injury and were probably necessary, "we agree that TBI should be explicitly highlighted as a nonmodifiable risk factor for postoperative neurocognitive disorders during informed consent discussions," the editorialists add.
On the basis of the findings, Collins and Campbell write that delaying nonurgent surgery for patients with m/sTBI and those with CT+ mTBI "should be strongly considered."
Future studies should include a closer examination of the potential influence of anesthetic techniques on postoperative outcomes with TBI and full neuropsychological testing, they add.
"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," they write.
The study was funded by the National Institutes of Health, the US Department of Veterans Affairs, US Department of Defense, the Neurosurgery Research and Education Foundation, and the Bagan Family Foundation. Full disclosures are included in the original article.
Kelli Whitlock Burton is a reporter for Medscape Medical News covering neurology and psychiatry.
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