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Published on: August 5, 2014
Variable Treatment Effects of Cranial Surgery in Pediatric Severe Traumatic Brain Injury
Vikas N Vattipally1, Patrick Kramer1, Sruthi Ranganathan2
1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Insights
Cranial surgery improved outcomes for children with severe traumatic brain injury (TBI). Younger children and those with severe injuries benefited most from operative intervention, suggesting tailored surgical guidelines.
Area of Science:
- Pediatric neurosurgery
- Trauma surgery
- Critical care medicine
Background:
- Severe traumatic brain injury (TBI) in children often leads to poor outcomes.
- Evidence regarding the efficacy of operative cranial surgery in pediatric severe TBI is limited.
- Identifying subgroups of pediatric patients who benefit most from surgery is crucial.
Purpose of the Study:
- To evaluate the association between cranial surgery and hospital discharge outcomes in pediatric severe TBI patients.
- To identify specific patient characteristics that predict a greater benefit from cranial surgery.
- To inform age- and injury-specific operative management guidelines.
Main Methods:
- Retrospective cohort study utilizing the Trauma Quality Improvement Program database (2017-2022).
- Included pediatric patients with severe TBI (Glasgow Coma Scale ≤8).
- Employed hierarchical regression and propensity score matching to analyze outcomes of cranial surgery (craniotomy, decompressive craniectomy) versus nonoperative management. A causal forest model identified heterogeneous treatment effects.
Main Results:
- Cranial surgery was performed in 23% of 2705 pediatric severe TBI patients.
- In propensity score-matched cohorts, cranial surgery correlated with higher odds of favorable discharge (OR, 1.53) and lower odds of mortality (OR, 0.28).
- Causal forest analysis indicated younger age (<12 years), lower GCS, higher ISS, significant midline shift, and absent pupillary reactivity as key factors influencing treatment benefit, with greatest benefit in the youngest and most severely injured.
Conclusions:
- Operative cranial intervention is associated with improved functional and survival outcomes in pediatric severe TBI compared to nonoperative care.
- The relative benefit of cranial surgery is most pronounced in children under 12 years and those with high-risk injury characteristics.
- Findings support the use of cranial surgery in selected pediatric severe TBI cases and can guide the refinement of management guidelines.
Background And Objectives:
Severe traumatic brain injury (TBI) in children is associated with poor outcomes, but evidence surrounding the role of operative cranial surgery in this patient population is limited. Thus, we sought to evaluate associations between cranial surgery and hospital discharge outcomes among pediatric patients with severe TBI and to identify patient subgroups most likely to benefit.
Methods:
This was a retrospective cohort study using data from the Trauma Quality Improvement Program database (2017-2022). Pediatric patients with severe TBI (presenting Glasgow Coma Scale ≤8) were included. Hierarchical regression and propensity score matching investigated associations between open cranial surgery (craniotomy or decompressive craniectomy) and favorable discharge disposition (home or inpatient rehabilitation). A causal forest model was constructed to identify heterogenous treatment effects of cranial surgery across strata of patient baseline and injury characteristics.
Results:
Among 2705 patients (median age, 13 years), 23% underwent cranial surgery. In both full and propensity score-matched cohorts (N = 998), risk-adjusted hierarchical regression analyses revealed that cranial surgery was associated with greater odds of favorable discharge (matched cohort odds ratio, 1.53; 95% CI, 1.04-2.27; P = .03) and lower odds of inpatient mortality (matched cohort odds ratio, 0.28; 95% CI, 0.18-0.45; P < .001). Causal forest analysis identified younger age, lower presenting Glasgow Coma Scale, higher Injury Severity Score, midline shift >5 mm, and the absence of pupil reactivity as key modifiers of treatment effect, with the greatest estimated benefit observed for patients younger than 12 years and for the most severely injured patients.
Conclusions And Relevance:
Cranial surgery was associated with improved functional and survival outcomes in pediatric severe TBI compared with nonoperative measures, with the largest relative benefit in patients younger than 12 years and those with high-risk clinical features. These findings support operative cranial intervention for selected pediatric patients and may inform refinement of age- and injury-specific operative management guidelines for pediatric severe TBI.
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