Surgical Versus Medical Management in Older Adults with Traumatic Brain Injury: A Systematic Review and Meta-analysis

Traumatic brain injury (TBI) in older adults is associated with high mortality and poor functional outcomes. However, optimal management remains uncertain, as evidence comparing surgical and medical strategies is limited, heterogeneous, and extrapolated from younger populations. We conducted a systematic review and meta-analysis to compare outcomes between surgical and medical management in this population.

PubMed, Embase, and Web of Science were searched from database inception to 8 December 2025. Studies including adults aged ≥ 60 years with TBI comparing surgical versus medical management were included. The primary outcome was favorable neurological outcome, while secondary outcomes included hospital length of stay (LOS) and mortality. Pooled estimates were calculated as risk ratios (RR) and mean differences (MD) using random-effects models with restricted maximum likelihood and Hartung-Knapp adjustment.

A total of 16 cohort studies comprising 132,823 patients were included. Surgical management was not associated with improved favorable neurological outcomes at discharge, 3, 6, or 12 months. However, it was associated with longer LOS (MD = 6.35 days, 95% CI: 2.55 to 10.14; p < 0.01). No differences were observed in in-hospital, 30-day, 3-month, 12-month, or 24-month mortality. Notably, surgical management was associated with a reduction in 6-month mortality (RR = 0.68, 95% CI: 0.51-0.92; p = 0.02).

In older adults with TBI, surgical management was associated with reduced 6-month mortality and longer hospital LOS, but not with improved functional outcomes, highlighting a dissociation between survival and recovery. This dissociation has important implications for clinical decision-making and patient and family counseling. Although this study represents the best available comparative evidence to date on surgical versus nonsurgical management in older adults with TBI, the findings should be interpreted with caution due to substantial heterogeneity and the low to very low certainty of the evidence. High-quality randomized controlled trials are needed to better define the role of surgery in this population. Trial Registration This systematic review and meta-analysis was prospectively registered in PROSPERO on November 21, 2025 (CRD420251236960).