One-Year Outcomes After Traumatic Brain Injury and Early Extracranial Surgery in the TRACK-TBI Study
- 3월 4일
- 4분 분량
2025년10월 10일
JAMA Netw Open Published Online: October 10, 2025
DOI: 10.1001/jamanetworkopen.2025.372271
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.
Key Points
Question Are traumatic brain injury (TBI) outcomes at 1 year worse in individuals exposed to extracranial surgery early after trauma compared with people unexposed?
Findings In this multicenter cohort study of 1150 participants that had follow-up at 1 year, participants undergoing extracranial surgery early after TBI and those with acute intracranial findings on computed tomography had worse functional, cognitive, and disability outcomes compared with general orthopedic trauma patients or those with TBI with imaging negative for acute intracranial findings.
Meaning The results suggest that for patients with TBI-induced radiographic abnormalities, early extracranial surgery may generate additional neurotoxic mediators that act as secondary insults to an already injured brain.
요약
· 중요성 외상성 뇌손상(TBI) 이후 초기에 시행되는 두개강 외 수술(extracranial surgery, EC surgery)은 인지 기능 저하와 관련된 위험이 있을 수 있다.
· 목적 TBI로 입원한 환자에서 입원 기간 동안 EC surgery를 받은 경우가, EC surgery를 받지 않은 환자에 비해 1년 후 임상 결과가 더 나쁜지를 평가하고자 하였다.
· 연구 설계, 장소, 대상자
본 연구는 전향적 관찰 연구인 TRACK-TBI(Transforming Research and Clinical Knowledge in TBI) 코호트 연구의 데이터를 이용한 후향적 2차 nested cohort 연구이다.
연구 대상 등록 기간: 2014년 2월 1일 ~ 2018년 8월 31일
장소: 미국 18개 Level I 외상센터
분석 기간: 2023년 7월 25일 ~ 2025년 7월 2일
연구 대상 포함 기준
▷17세 이상
▷외상 후 24시간 이내 응급실에서 입원
▷Glasgow Coma Scale(GCS) 점수 확인 가능
▷두부 CT 시행
▷두개내 수술(intracranial surgery)을 시행하지 않은 환자
이 환자들은 TBI 이후 최대 1년 동안 추적 관찰되었다.
노출변수
입원 기간 동안 EC surgery를 받은 환자와 받지 않은 환자를 비교하였다.
다음과 같은 손상 하위군에서 분석하였다.
1. Orthopedic trauma controls (OTCs)→ 정형외과 외상 환자
2. Moderate-severe TBI→ GCS 3–12
3. 경증 TBI (GCS 13–15) 중
▷CT positive (CT+): 급성 두개내 병변 존재
▷CT negative (CT−): 급성 두개내 병변 없음
· 주요 평가지표
기능적 결과: Glasgow Outcome Scale–Extended (GOSE-TBI)
인지 기능: Trail Making Test (Trails) A, B
장애 정도: Disability Rating Scale (DRS)
삶의 질: Quality of Life After Brain Injury Overall Scale (QOLIBRI-OS)
분석 방법
baseline 특성 차이 및 결측 데이터를 보정하기 위해propensity weighting을 적용한 고정효과 선형 회귀모형을 사용하였다.
· 결과
총 1835명 환자
남성: 1279명 (70%)
평균 연령: 42.2 ± 17.8세
수술 여부
▷EC surgery 없음: 1349명 (74%)
▷EC surgery 시행: 486명 (26%)
1년 추적 가능 환자: 1150명 (63%)
· 주요 결과
CT+ TBI 및 중등도-중증 TBI 환자에서 EC surgery 시행 환자는 수술을 받지 않은 환자보다
다음 결과가 유의하게 나빴다.
기능적 결과 (GOSE-TBI)
▷CT+ TBI
B = −0.5 [95% CI −0.92 ~ −0.2]
▷Moderate-severe TBI
B = −1.25 [95% CI −1.65 ~ −0.85]
인지 기능 (Trail Making Test B)
▷CT+ TBI
B = 22.7 [95% CI, 7.4-38.1]
▷Moderate-severe TBI
B = 47.9 [95% CI, 27.0-68.8]
→ 시간 증가 = 인지 기능 저하
장애 정도 (DRS)
▷CT+ TBI
B = 2.47 [95% CI, 1.30-3.64]
▷Moderate-severe TBI
B = 3.53 [95% CI, 2.19-4.87]
→ 점수 증가 = 장애 증가
삶의 질 (QOLIBRI-OS)
▷ 중등도-중증 TBI 환자에서
B = −15.1 [95% CI, 2.19-4.87]
→ 삶의 질 감소
· 반면 다음 환자군에서는 EC surgery와 예후 사이 연관성이 없었다.
▷ Orthopedic trauma control
▷ CT− TBI
GOSE-TBI
B = 0.02 [95% CI −0.24 ~ 0.27]
→ 유의한 연관 없음
· 결론 및 임상적 의미
이 코호트 연구에서 초기 두개강 외 수술(EC surgery)은 중등도에서 중증 외상성 뇌손상(TBI) 환자이거나 초기 CT에서 두개내 이상 소견이 있는 환자에서입원 당시 Glasgow Coma Scale(GCS) 점수와 관계없이 기능적 결과, 인지 기능, 그리고 장애 정도가 더 나쁜 결과와 연관되는 것으로 나타났다.
반면 정형외과 외상 환자나 CT에서 이상 소견이 없는 TBI 환자(CT− TBI)에서는 이러한 연관성이 관찰되지 않았다.
향후 연구를 통해 수술 시점(surgical timing)이나 다른 치료적 중재가 이러한 장기적인 기능 저하를 개선할 수 있는지를 규명할 필요가 있다.
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