Surgical Versus Medical Management for Severe Pediatric Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Area of Science:

• Neurosurgery
• Pediatric Critical Care
• Trauma Surgery

Background:

• Severe pediatric traumatic brain injury (TBI) necessitates interventions to manage intracranial pressure.
• Decompressive craniectomy (DC) is a surgical option, but its efficacy in children is debated.
• Existing evidence comparing DC to medical management (MM) in pediatric TBI is limited and conflicting.

Purpose of the Study:

• To conduct a meta-analysis evaluating the comparative outcomes of DC versus MM in pediatric patients with severe TBI.
• To synthesize current evidence to inform clinical decision-making and guideline development.

Main Methods:

• Systematic literature search following PRISMA guidelines up to October 2025.
• Inclusion of randomized controlled trials and observational studies comparing DC and MM in patients under 18 with severe TBI.
• Application of random-effects models for meta-analysis of clinical outcomes.

Main Results:

• Analysis included 553 patients undergoing DC and 2336 patients receiving MM.
• No significant difference in favorable functional outcomes (Glasgow Outcome Scale) or mortality was found between DC and MM groups.
• DC was associated with significantly longer intensive care unit (ICU) stays (mean difference 6.2 days) and a trend towards longer hospital stays.

Conclusions:

• Decompressive craniectomy (DC) does not demonstrate clear survival or functional advantages over medical management (MM) in pediatric severe TBI.
• DC is associated with increased length of ICU and hospital stays.
• Further high-quality, prospective, multicenter studies are essential to validate these findings and establish pediatric-specific guidelines.