Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Mar 1;159(3):248-259.
doi: 10.1001/jamasurg.2023.6374.

Clinical Outcomes After Traumatic Brain Injury and Exposure to Extracranial Surgery: A TRACK-TBI Study

Christopher J Roberts  1   2 , Jason Barber  3 , Nancy R Temkin  3   4 , Athena Dong  1   2 , Claudia S Robertson  5 , Alex B Valadka  6 , John K Yue  7 , Amy J Markowitz  8 , Geoffrey T Manley  7   8 , Lindsay D Nelson  9   10 ; Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) Investigators; Neeraj Badjatia  11 , Ramon Diaz-Arrastia  12 , Ann-Christine Duhaime  13 , V Ramana Feeser  14 , Shankar Gopinath  5 , Ramesh Grandhi  15 , Ruchira Jha  16 , C Dirk Keene  17 , Christopher Madden  18 , Michael McCrea  9 , Randall Merchant  19 , Laura B Ngwenya  20 , Richard B Rodgers  21 , David Schnyer  22 , Sabrina R Taylor  23 , Ross Zafonte  24
Affiliations

Clinical Outcomes After Traumatic Brain Injury and Exposure to Extracranial Surgery: A TRACK-TBI Study

Christopher J Roberts et al. JAMA Surg. .

Abstract

Importance: Traumatic brain injury (TBI) is associated with persistent functional and cognitive deficits, which may be susceptible to secondary insults. The implications of exposure to surgery and anesthesia after TBI warrant investigation, given that surgery has been associated with neurocognitive disorders.

Objective: To examine whether exposure to extracranial (EC) surgery and anesthesia is related to worse functional and cognitive outcomes after TBI.

Design, setting, and participants: This study was a retrospective, secondary analysis of data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a prospective cohort study that assessed longitudinal outcomes of participants enrolled at 18 level I US trauma centers between February 1, 2014, and August 31, 2018. Participants were 17 years or older, presented within 24 hours of trauma, were admitted to an inpatient unit from the emergency department, had known Glasgow Coma Scale (GCS) and head computed tomography (CT) status, and did not undergo cranial surgery. This analysis was conducted between January 2, 2020, and August 8, 2023.

Exposure: Participants who underwent EC surgery during the index admission were compared with participants with no surgery in groups with a peripheral orthopedic injury or a TBI and were classified as having uncomplicated mild TBI (GCS score of 13-15 and negative CT results [CT- mTBI]), complicated mild TBI (GCS score of 13-15 and positive CT results [CT+ mTBI]), or moderate to severe TBI (GCS score of 3-12 [m/sTBI]).

Main outcomes and measures: The primary outcomes were functional limitations quantified by the Glasgow Outcome Scale-Extended for all injuries (GOSE-ALL) and brain injury (GOSE-TBI) and neurocognitive outcomes at 2 weeks and 6 months after injury.

Results: A total of 1835 participants (mean [SD] age, 42.2 [17.8] years; 1279 [70%] male; 299 Black, 1412 White, and 96 other) were analyzed, including 1349 nonsurgical participants and 486 participants undergoing EC surgery. The participants undergoing EC surgery across all TBI severities had significantly worse GOSE-ALL scores at 2 weeks and 6 months compared with their nonsurgical counterparts. At 6 months after injury, m/sTBI and CT+ mTBI participants who underwent EC surgery had significantly worse GOSE-TBI scores (B = -1.11 [95% CI, -1.53 to -0.68] in participants with m/sTBI and -0.39 [95% CI, -0.77 to -0.01] in participants with CT+ mTBI) and performed worse on the Trail Making Test Part B (B = 30.1 [95% CI, 11.9-48.2] in participants with m/sTBI and 26.3 [95% CI, 11.3-41.2] in participants with CT+ mTBI).

Conclusions and relevance: This study found that exposure to EC surgery and anesthesia was associated with adverse functional outcomes and impaired executive function after TBI. This unfavorable association warrants further investigation of the potential mechanisms and clinical implications that could inform decisions regarding the timing of surgical interventions in patients after TBI.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Temkin reported receiving grants from the US federal government during the conduct of the study. Dr Robertson reported receiving grants from the National Institutes of Health (NIH) and the US Department of Defense during the conduct of the study. Dr Markowitz reported receiving a contract from the US Department of Defense/Medical Technology Enterprise Consortium TRACK-TBI Network during the conduct of the study. Dr Manley reported a contract from the US Department of Defense/Medical Technology Enterprise Consortium and grants from the US Department of Defense, National Institute of Neurological Disorders and Stroke (NINDS), and National Football League Scientific Advisory Board during the conduct of the study and funding from NeuroTrauma Sciences LLC and One Mind outside the submitted work. Dr Nelson reported receiving grants from Centers for Disease Control and Prevention, National Institute of Neurological Disorders and Stroke, Medical Technology Enterprise, Medical College of Wisconsin, US Department of Defense, and NINDS outside the submitted work. Dr Diaz-Arrastia reported receiving grants and stock options from BrainBox LLC, stock from Nova Signal, consulting fees from MesoScale Discoveries, and consulting fees from Ischemix outside the submitted work. Dr Duhaime reported receiving grants from the NIH during the conduct of the study. Dr Grandhi reported receiving personal fees from Balt Neurovascular, Cerenovus, Integra, and Medtronic Neurovascular outside the submitted work. Dr Jha reported serving on the advisory board for Biogen. Dr Madden reported receiving grants from NIH during the conduct of the study. Dr McCrea reported receiving grants from the NIH during the conduct of the study and consulting fees from Neurotrauma Sciences outside the submitted work. Dr Ngwenya reported receiving grants from Abbott and Biogen outside the submitted work. Dr Zafonte reported receiving royalties from Springer/Demos, serving as a member of the editorial board of Journal of Neurotrauma and Frontiers in Neurology, serving on the scientific advisory board of Myomo, Nanodiagnostics, and Onecare.ai, and receiving funds from the National Football League Players Association. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Functional Outcomes at 2 Weeks and 6 Months After Injury
Functional outcomes quantified using Glasgow Outcome Scale–Extended for Traumatic Brain Injury (GOSE-TBI) and all injuries (GOSE-ALL) based on injury group and exposure to extracranial (EC) surgery. Additional data provided in eTable 4 for total sample sizes and mean (SD). CT+ mTBI indicates computed tomography–positive mild traumatic brain injury; CT− mTBI, computed tomography–negative mild traumatic brain injury; GR, good recovery; MD, moderate disability; OTC, orthopedic trauma control; SD, severe disability.
Figure 2.
Figure 2.. Cognitive Outcomes at 6 Months After Injury
Cognitive outcomes quantified using the Trail Making Test Part A (A) and Trail Making Test Part B (B) (lower scores indicate faster or better completion times) classified by injury group and exposure to extracranial (EC) surgery. Differences were found between injury groups, which are not displayed, when assessed in the patients in the no surgery group only, which were calculated based on contrasts from the interaction regression models and regression coefficients in Table 2. Differences between injury severity in the EC surgery group were not examined because of the analysis approach. Bars are raw unadjusted means; error bars indicate SEMs. CT+ mTBI indicates computed tomography–positive mild traumatic brain injury; CT− mTBI, computed tomography–negative mild traumatic brain injury; GCS, Glasgow Coma Scale; OTC, orthopedic trauma control. aP < .01 for differences between nonsurgical and EC surgery groups with no adjustment for multiple comparisons.
Figure 3.
Figure 3.. Impairment on Neuropsychological Outcomes at 6 Months After Injury
Descriptive data for all cohorts grouped by exposure to extracranial (EC) surgery. Data are the percentage of participants in each group who met clinical criteria for impairment. CT+ mTBI indicates computed tomography–positive mild traumatic brain injury; CT− mTBI, computed tomography–negative mild traumatic brain injury; GCS, Glasgow Coma Scale; OTC, orthopedic trauma control.
See this image and copyright information in PMC

Comment in

References

    1. Dewan MC, Rattani A, Gupta S, et al. . Estimating the global incidence of traumatic brain injury. J Neurosurg. 2018;130(4):1080-1097. doi:10.3171/2017.10.JNS17352 - DOI - PubMed
    1. Abcejo AS, Savica R, Lanier WL, Pasternak JJ. Exposure to surgery and anesthesia after concussion due to mild traumatic brain injury. Mayo Clin Proc. 2017;92(7):1042-1052. doi:10.1016/j.mayocp.2017.03.012 - DOI - PubMed
    1. Weiser TG, Regenbogen SE, Thompson KD, et al. . An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139-144. doi:10.1016/S0140-6736(08)60878-8 - DOI - PubMed
    1. McIsaac DI, Abdulla K, Yang H, et al. . Association of delay of urgent or emergency surgery with mortality and use of health care resources: a propensity score-matched observational cohort study. CMAJ. 2017;189(27):E905-E912. doi:10.1503/cmaj.160576 - DOI - PMC - PubMed
    1. Klestil T, Röder C, Stotter C, et al. . Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. Sci Rep. 2018;8(1):13933. doi:10.1038/s41598-018-32098-7 - DOI - PMC - PubMed

Publication types