Timing of surgery after multisystem injury with traumatic brain injury

Effect on neuropsychological and functional outcome

Marjorie C. Wang, Nancy R. Temkin, Richard A. Deyo, Gregory Jurkovich, Jason Barber, Sureyya Dikmen

Research output: Contribution to journalArticle

22 Citations (Scopus)

Abstract

OBJECTIVE: The optimal timing for noncranial surgery after multisystem injury is not known. Early surgery may lead to decreased pulmonary complications and length of stay, but also predispose to secondary brain injury if decreased cerebral perfusion occurs intraoperatively. Previous work has not consistently evaluated neuropsychological or functional outcome. We sought to determine whether 6-month neuropsychological and functional outcome was associated with timing of noncranial surgery after traumatic brain injury. MATERIALS: We performed a cohort study to evaluate the effect of timing of non-neurosurgical operative interventions on neuropsychological and functional outcome, morbidity, and mortality. Early surgery was defined as ≤24 hours after injury, and late surgery, >24 hours after injury but during the same admission. Patients with a nonoperative brain injury and an operative facial or orthopedic fracture were selected from two randomized trials previously performed at our Level I trauma center. Data were abstracted from medical records and outcome had been prospectively gathered as part of the two clinical trials. RESULTS: Patients undergoing early or late surgery had similar demographics, overall injury severity, traumatic brain injury severity, and admission characteristics. The early group had more open orthopedic fractures, but also underwent multiple operations more often than did the late group. At 6 months postinjury, patients in the early group had a better composite neuropsychological score than did those in the late group on unadjusted analysis and after including a propensity score. After adjusting for potential confounders, this difference was significant. No significant differences in return to work or Glasgow Outcome Score were noted. The late group had a higher incidence of pneumonia and a longer hospital stay (p < 0.10). CONCLUSIONS: In traumatic brain injury patients with multisystem trauma, early timing of orthopedic and facial fracture fixation under general anesthesia was not associated with worse neuropsychological or functional outcome when compared with the outcomes associated with late surgery. Clinical conclusions may be limited by inherent selection bias and unmeasured confounding. However, these results contribute to equipoise regarding timing of surgery after multiple injuries, and emphasize the need for a randomized trial.

Original languageEnglish (US)
Pages (from-to)1250-1258
Number of pages9
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume62
Issue number5
DOIs
StatePublished - May 1 2007
Externally publishedYes

Fingerprint

Wounds and Injuries
Orthopedics
Brain Injuries
Length of Stay
Fracture Fixation
Propensity Score
Open Fractures
Return to Work
Traumatic Brain Injury
Selection Bias
Multiple Trauma
Trauma Centers
General Anesthesia
Medical Records
Pneumonia
Cohort Studies
Perfusion
Demography
Clinical Trials
Morbidity

Keywords

  • Functional outcome
  • Multisystem injury
  • Neuropsychological outcome
  • Timing of surgery
  • Traumatic brain injury

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Timing of surgery after multisystem injury with traumatic brain injury : Effect on neuropsychological and functional outcome. / Wang, Marjorie C.; Temkin, Nancy R.; Deyo, Richard A.; Jurkovich, Gregory; Barber, Jason; Dikmen, Sureyya.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 62, No. 5, 01.05.2007, p. 1250-1258.

Research output: Contribution to journalArticle

Wang, Marjorie C. ; Temkin, Nancy R. ; Deyo, Richard A. ; Jurkovich, Gregory ; Barber, Jason ; Dikmen, Sureyya. / Timing of surgery after multisystem injury with traumatic brain injury : Effect on neuropsychological and functional outcome. In: Journal of Trauma - Injury, Infection and Critical Care. 2007 ; Vol. 62, No. 5. pp. 1250-1258.
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abstract = "OBJECTIVE: The optimal timing for noncranial surgery after multisystem injury is not known. Early surgery may lead to decreased pulmonary complications and length of stay, but also predispose to secondary brain injury if decreased cerebral perfusion occurs intraoperatively. Previous work has not consistently evaluated neuropsychological or functional outcome. We sought to determine whether 6-month neuropsychological and functional outcome was associated with timing of noncranial surgery after traumatic brain injury. MATERIALS: We performed a cohort study to evaluate the effect of timing of non-neurosurgical operative interventions on neuropsychological and functional outcome, morbidity, and mortality. Early surgery was defined as ≤24 hours after injury, and late surgery, >24 hours after injury but during the same admission. Patients with a nonoperative brain injury and an operative facial or orthopedic fracture were selected from two randomized trials previously performed at our Level I trauma center. Data were abstracted from medical records and outcome had been prospectively gathered as part of the two clinical trials. RESULTS: Patients undergoing early or late surgery had similar demographics, overall injury severity, traumatic brain injury severity, and admission characteristics. The early group had more open orthopedic fractures, but also underwent multiple operations more often than did the late group. At 6 months postinjury, patients in the early group had a better composite neuropsychological score than did those in the late group on unadjusted analysis and after including a propensity score. After adjusting for potential confounders, this difference was significant. No significant differences in return to work or Glasgow Outcome Score were noted. The late group had a higher incidence of pneumonia and a longer hospital stay (p < 0.10). CONCLUSIONS: In traumatic brain injury patients with multisystem trauma, early timing of orthopedic and facial fracture fixation under general anesthesia was not associated with worse neuropsychological or functional outcome when compared with the outcomes associated with late surgery. Clinical conclusions may be limited by inherent selection bias and unmeasured confounding. However, these results contribute to equipoise regarding timing of surgery after multiple injuries, and emphasize the need for a randomized trial.",
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