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
Observational Study
. 2025 Oct 1;8(10):e2537271.
doi: 10.1001/jamanetworkopen.2025.37271.

One-Year Outcomes After Traumatic Brain Injury and Early Extracranial Surgery in the TRACK-TBI Study

Christopher J Roberts  1   2 , Amelia W Maiga  3   4   5 , Jason Barber  6 , Nancy R Temkin  6   7 , Ruturaj Vala  1 , Mayur B Patel  3   4   5 , Claudia S Robertson  8 , Alex B Valadka  9 , John K Yue  10 , Amy J Markowitz  11 , Geoffrey T Manley  10   11 , Lindsay D Nelson  12   13 ; Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) Investigators; Ann-Christine Duhaime  14 , Brandon Foreman  15 , Ramesh Grandhi  16 , C Dirk Keene  17 , Vijay Krishnamoorthy  18 , Christine Mac Donald  6 , Michael McCrea  12 , Randall Merchant  19 , Laura B Ngwenya  20 , Ava Puccio  21 , Richard B Rodgers  22 , David Schnyer  23 , Sabrina R Taylor  24 , Ross Zafonte  25
Affiliations
Observational Study

One-Year Outcomes After Traumatic Brain Injury and Early Extracranial Surgery in the TRACK-TBI Study

Christopher J Roberts et al. JAMA Netw Open. .

Abstract

Importance: Exposure to extracranial (EC) surgery early after traumatic brain injury (TBI) is associated with cognitive risks.

Objective: To examine whether exposure to EC surgery during a TBI index admission is associated with worse outcomes at 1 year compared with no EC surgery.

Design, setting, and participants: This was a retrospective secondary nested cohort study of the prospective, observational Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) cohort study that enrolled participants from February 1, 2014, through August 31, 2018, at 18 US level I trauma centers. Participants aged 17 years or older who were admitted to an inpatient unit from the emergency department (ED) within 24 hours of trauma, had a known Glasgow Coma Scale (GCS) score and head computed tomography (CT) imaging, and did not undergo intracranial surgery were followed for up to 1 year after TBI and were analyzed for this study from July 25, 2023, to July 2, 2025.

Exposure: Participants that underwent EC surgery during the index admission were compared with nonsurgical participants within the following injury subgroups: orthopedic trauma controls (OTCs), moderate-severe TBI (GCS 3-12), and computed tomography (CT) scan results that were positive (CT+) or negative (CT-) for acute intracranial findings along with a GCS score of 13 to 15.

Main outcomes and measures: Brain injury-specific functional outcomes (Glasgow Outcome Scale-Extended [GOSE-TBI]), cognition (Trail Making Test [Trails] parts A and B), Disability Rating Scale (DRS), and Quality of Life After Brain Injury-Overall Scale (QOLIBRI-OS). A fixed-effects linear regression model with propensity weighting for missing outcome and group imbalance in baseline characteristics was used.

Results: Of the 1835 participants, 1279 (70%) were male, with mean (SD) age of 42.2 (17.8) years; 1349 participants (74%) were nonsurgical and 486 (26%) underwent EC surgery. In the 1150 participants (63%) followed up at 1 year, after propensity weighting, patients undergoing EC surgery in both the CT+ TBI and moderate-severe TBI subgroups had significantly worse GOSE-TBI (B, -0.57 [95% CI, -0.92 to -0.22] and -1.25 [95% CI, -1.65 to -0.85], respectively), Trails part B (B, 22.7 [95% CI, 7.4-38.1] and 47.9 [95% CI, 27.0-68.8]), and DRS (B, 2.47 [95% CI, 1.30-3.64] and 3.53 [95% CI, 2.19-4.87]) scores compared with nonsurgical participants. QOLIBRI-OS was worse after EC surgery vs no EC surgery in the subgroup with moderate-severe TBI (B, -15.1 [95% CI, -24.3 to -5.9]). There was no association of EC surgery with outcomes in the OTC or CT- TBI subgroups. For example, GOSE-TBI was not associated with EC surgery in the CT- TBI subgroup (B, 0.02 [95% CI, -0.24 to 0.27]).

Conclusions and relevance: In this cohort study, early EC surgery was associated with adverse function, cognition, and disability after TBI rated as moderate-severe or with radiographic abnormalities on CT scan regardless of GCS at index admission but not after orthopedic trauma or CT- TBI. Further studies may help determine whether surgical timing or other interventions can improve the observed long-term deficits.

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 Patel reported being appointed as Ingram Chair in Surgical Sciences (Vanderbilt University) and receiving endowed chair support during the conduct of the study; receiving grants from the US Department of Defense (DOD) for multiple traumatic brain injury (TBI) and trauma-related and critical care studies and from the National Institutes of Health (NIH); receiving research support from CSL Behring for the Trauma and Prothrombin Complex Concentrate (TAP) Trial; serving on the Liberate Medical scientific advisory board with no compensation; receiving personal fees from Elsevier for serving as associate editor of a textbook outside the submitted work; and having a patent for image segmentation via multi-atlas fusion with context learning. Dr Robertson reported receiving grants from the NIH and DOD during the conduct of the study. Dr Yue reported receiving a Neurosurgery Research and Education Foundation Fellowship Grant awarded to the University of California, San Francisco (UCSF) during the conduct of the study and receiving grants from the UCSF Weill Institute for the Neurosciences and a UCSF Innovation Ventures Catalyst Award Grant, awarded to UCSF, outside the submitted work. Ms Markowitz reported receiving a grant from the DOD–Medical Technology Enterprise Consortium (MTEC) Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Network and receiving the Specimen Collection for the Evaluation of Traumatic Brain Injury in Adults—Training Set from Abbott Laboratories outside the submitted work. Dr Manley reported receiving TRACK-TBI grants from the National Institute of Neurological Disorders and Stroke (NINDS) and receiving TRACK-TBI Precision Medicine and MTEC TRACK-TBI Network grants from the DOD during the conduct of the study; receiving the Specimen Collection for the Evaluation of Traumatic Brain Injury in Adults and Pediatrics from Abbott Laboratories; and receiving grants from the National Football League scientific advisory board for TRACK-TBI Longitudinal outside the submitted work. Dr Nelson reported receiving grants from the NINDS during the conduct of the study; grant funding from the DOD, Centers for Disease Control and Prevention, Medical College of Wisconsin (MCW) Advancing a Healthier Wisconsin Endowment, and NIH for unrelated TBI research outside the submitted work; and consulting income from Resolys Bio, Inc. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Functional Outcomes at 1 Year After Traumatic Brain Injury (TBI)
Functional outcomes were quantified using the Glasgow Outcome Scale–Extended for brain injury (GOSE-TBI) and for all injuries (GOSE-all) at 1 year after TBI based on injury group and exposure to extracranial (EC) surgery without intracranial surgery, excluding deaths within 2 weeks of injury. Graphs show raw data. Significance is denoted for differences between nonsurgical and EC surgery groups in the interaction regression models in Table 2 with no adjustment for multiple comparisons. Additional data are provided in eTable 3 in Supplement 1. CT− indicates that CT imaging of the head was considered negative for acute intracranial findings; GR, good recovery; MD, moderate disability; OTC, orthopedic trauma control; SD, severe disability. aP < .001. bP = .002.
Figure 2.
Figure 2.. Outcomes for Cognition, Disability, and Quality of Life at 1 Year After Traumatic Brain Injury (TBI)
A, Outcome was quantified as number of seconds to complete; maximum score, 101 seconds, and faster score is better. B, Outcome was quantified as number of seconds to complete; maximum score, 301 seconds, and faster score is better. C, Score range, 0-29, and lower score is better. D, Score range, 0-100, and higher score is better. Outcomes were classified by injury group and exposure to extracranial (EC) surgery without intracranial surgery. Graphs show raw unadjusted means, and whiskers indicate SEMs. Significance is denoted for differences between nonsurgical and EC surgery groups in the interaction regression models in Table 2 with no adjustment for multiple comparisons. CT− indicates CT scan of the head was considered negative for acute intracranial findings. aP = .03. bP < .001. cP = .004. dP = .001.
See this image and copyright information in PMC

References

    1. Evered L, Silbert B, Scott DA, Zetterberg H, Blennow K. Association of changes in plasma neurofilament light and tau levels with anesthesia and surgery: results from the CAPACITY and ARCADIAN studies. JAMA Neurol. 2018;75(5):542-547. doi: 10.1001/jamaneurol.2017.4913 - DOI - PMC - PubMed
    1. Feinstein I, Wilson EN, Swarovski MS, Andreasson KI, Angst MS, Greicius MD. Plasma biomarkers of tau and neurodegeneration during major cardiac and noncardiac surgery. JAMA Neurol. 2021;78(11):1407-1409. doi: 10.1001/jamaneurol.2021.2823 - DOI - PMC - PubMed
    1. Tang JX, Baranov D, Hammond M, Shaw LM, Eckenhoff MF, Eckenhoff RG. Human Alzheimer and inflammation biomarkers after anesthesia and surgery. Anesthesiology. 2011;115(4):727-732. doi: 10.1097/ALN.0b013e31822e9306 - DOI - PMC - PubMed
    1. Reese M, Wong MK, Cheong V, et al. ; Markers of Alzheimer’s Disease and neuroCognitive Outcomes after Perioperative Care (MADCO-PC) Investigators . Cognitive and cerebrospinal fluid Alzheimer’s disease-related biomarker trajectories in older surgical patients and matched nonsurgical controls. Anesthesiology. 2024;140(5):963-978. doi: 10.1097/ALN.0000000000004924 - DOI - PMC - PubMed
    1. Williams-Russo P, Sharrock NE, Mattis S, Szatrowski TP, Charlson ME. Cognitive effects after epidural vs general anesthesia in older adults: a randomized trial. JAMA. 1995;274(1):44-50. doi: 10.1001/jama.1995.03530010058035 - DOI - PubMed

Publication types