Long-term functional outcomes following pediatric decompressive craniectomy for traumatic brain injury

Determine whether there is a difference in 5-year functional outcomes between pediatric head trauma cases who received DC vs. non-operative management (NOM).

A seven-year (2017-2024) retrospective, case-control study of 195 pediatric trauma admissions (ages 2-18) at two Level-1 Trauma Centers. Subjects with primary head trauma and GCS ≤ 12 were included. Cases were divided into two matched cohorts based on age, sex, and injury severity. The DC group was characterized by surgical indication, and non-operative management (NOM) interventions were recorded by tier per Brain Trauma Foundation guidelines. Outcomes were assessed annually over five years using GOSE and KOSCHI. Statistical tests included χ², t-test, and CMH test for outcome shifts.

Twenty-six matched pairs (n = 52) were included in the final analysis. The DC group had markedly worse intracranial pathology, including midline shift (38.46% DC vs 0% NOM, p = .001) and cisternal compression (65.38% DC vs 7.69% NOM, p < .001), along with higher hospital mortality (15.38% DC vs 0% NOM). CMH shift testing of GOSE and KOSCHI demonstrated comparable outcomes between cohorts from years one through four (p = .068). At five years, the NOM group exhibited a trend toward better outcomes (p = .046), although interpretation was limited by a small sample size at this time point (n = 5), with the remainder lost to follow-up. Notably, no DC survivors with available follow-up data demonstrated functional decline over time. On follow-up, neurological symptoms sequelae were more common in the DC group, while psychiatric complaints were more frequently reported in the NOM group.

Despite significantly worse intracranial pathology, DC patients who remained in follow-up achieved comparable functional outcomes to NOM patients through four years.