Early neurosurgical procedures enhance survival in blunt head injury: propensity score analysis.
BACKGROUND
Studies of trauma systems have identified traumatic brain injury as a frequent cause of death or disability. Due to the heterogeneity of patient presentations, practice variations, and potential for secondary brain injury, the importance of early neurosurgical procedures upon survival remains controversial. Traditional observational outcome studies have been biased because injury severity and clinical prognosis are associated with use of such interventions.


OBJECTIVE
We used propensity analysis to investigate the clinical efficacy of early neurosurgical procedures in patients with traumatic brain injury.


METHODS
We analyzed a retrospectively identified cohort of 518 consecutive patients (ages 18-65 years) with blunt, traumatic brain injury (head Abbreviated Injury Scale score of >or= 3) presenting to the emergency department of a Level-1 trauma center. The propensity for a neurosurgical procedure (i.e., craniotomy or ventriculostomy) in the first 24 h was determined (based upon demographic, clinical presentation, head computed tomography scan findings, intracranial pressure monitor use, and injury severity). Multivariate logistic regression models for survival were developed using both the propensity for a neurosurgical procedure and actual performance of the procedure.


RESULTS
The odds of in-hospital death were substantially less in those patients who received an early neurosurgical procedure (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.05-0.41). The mortality benefit of early neurosurgical intervention persisted after exclusion of patients who died within the first 24 h (OR 0.13; 95% CI 0.04-0.48).


CONCLUSIONS
Analysis of observational data after adjustment using the propensity score for a neurosurgical procedure in the first 24 h supports the association of early neurosurgical intervention and patient survival in the setting of significant blunt, traumatic brain injury. Transfer of at-risk head-injured patients to facilities with high-level neurosurgical capabilities seems warranted.
Hedges
Jerris R
JR
Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon, USA.
Newgard
Craig D
CD
Veum-Stone
Judith
J
Selden
Nathan R
NR
Adams
Annette L
AL
Diggs
Brian S
BS
Arthur
Melanie
M
Mullins
Richard J
RJ
D000328:Adult; D001930:Brain Injuries / Q000175:diagnosis / Q000601:surgery*; D003399:Craniotomy / Q000706:statistics & numerical data*; D003657:Decision Making; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009922:Oregon; D017063:Outcome Assessment, Health Care; D010360:Patient Transfer; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D016019:Survival Analysis; D013997:Time Factors; D014193:Trauma Centers; D014696:Ventriculostomy / Q000706:statistics & numerical data; D014949:Wounds, Nonpenetrating / Q000175:diagnosis / Q000601:surgery*