Recent research shows that extracranial (EC) surgeries and anesthesia shortly after a traumatic brain injury (TBI) are associated with worse functional and cognitive outcomes.
Patients with traumatic brain injuries of all severities had worse functional recovery and poorer neurocognitive outcomes at 2 weeks and 6 months if they underwent surgery compared to those who did not. Those with moderate to severe TBI (m/sTBI) and complicated mild TBI with positive CT findings (CT+ mTBI) reported the poorest outcomes.
„These results support the hypothesis that surgery and anesthesia, or alternatively, multiple trauma, may need to be included in the list of secondary insults that should be avoided whenever possible to protect the brain after a traumatic brain injury,“ said lead researcher Christopher J. Roberts, MD, PhD of the Department of Anesthesiology at the Medical College of Wisconsin and Zablocki Veterans Affairs Medical Center, Milwaukee, and co-authors.
The findings were published online on December 13 in JAMA Surgery.
Impact on Recovery
For the retrospective study, researchers examined data from the „Transforming Research and Clinical Knowledge in Traumatic Brain Injury“ study, a prospective cohort longitudinal study conducted in 18 level I trauma centers in the United States between 2014 and 2018.
The study included 1,835 patients (average age 42 years; 70% male) in this secondary analysis who were all examined within 24 hours of the traumatic brain injury and had not undergone skull surgery for the injury at the start of the study.
During the study period, 486 patients underwent EC surgery, mainly due to limb fractures. Functional recovery after a traumatic brain injury was measured using the Glasgow Outcome Scale – Extended for all injuries (GOSE-ALL) and specifically for brain injuries (GOSE-TBI). Neurocognitive outcomes were measured using the Trail Making Test parts A and B.
Those who underwent EC surgery had significantly poorer functional recovery and neurocognitive outcomes at 2 weeks and 6 months compared to the non-surgical group, regardless of the severity of the traumatic brain injury. The worst outcomes were found in patients with m/sTBI (P < .001) and CT+ mTBI (P = .001) after 6 months.
„Most notably, in both the m/sTBI group and the CT+ mTBI group, the effect of EC surgery at 6 months on the GOSE-ALL and GOSE-TBI scores was comparable, suggesting that EC surgery could affect brain recovery after TBI,“ the authors wrote.
Delaying Non-Urgent Surgeries
In an accompanying editorial, Caitlin R. Collins, MD, MPH, and Andre Campbell, MD, both from the Department of Surgery at the School of Medicine, University of California, San Francisco, wrote that the study „provides a necessary foundation for more informed risk-benefit analysis regarding surgery in these patients.“
Research suggests that approximately 50% of patients with mild traumatic brain injury undergo surgery within a week of their injury, and 5% undergo procedures or surgeries unrelated to the trauma that caused their traumatic brain injury.
Although most EC surgeries included in the study were related to the traumatic injury and likely necessary, „we agree that TBI should be specifically highlighted as an unmodifiable risk factor for postoperative neurocognitive disorders in discussions regarding informed consent,“ the editors added.
Based on the results, Collins and Campbell wrote that delaying non-urgent surgical procedures in patients with m/sTBI and CT+ mTBI „should be seriously considered.“
Future studies should include a more detailed examination of the potential impact of anesthesia techniques on postoperative outcomes in TBI and comprehensive neuropsychological testing, they added.
„While opportunities for continued investigation and enlightenment remain large, this study lays the groundwork for further inquiry and provides a platform for the refinement and optimization of care for patients with traumatic brain injury undergoing extracranial surgery,“ they wrote.
The study was funded by the National Institutes of Health, the US Department of Veterans Affairs, the 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.