Introduction: Surgery for patients with traumatic brain injury (TBI) remains controversial. Studies suggest that craniectomy (CE) may be superior to craniotomy (CO) by reducing intracranial pressure and limiting post-operative brain swelling. Few studies report comprehensive long-term functional and quality of life outcomes.

Methods: All patients with TBI who underwent CE or CO were extracted from the TBI Model Systems database from 2000-2012. A 1:1 propensity matching with replacement technique was used to match baseline characteristics including age, Glasgow Coma Score, Marshall CT score, TBI sub-type, and intracranial hypertension across groups. The matched sample was analyzed for outcomes during hospitalization, acute rehabilitation, and up to two years follow-up.

Results: We identified 1,470 patients in both CE and CO groups. Baseline characteristics were well-matched between groups (standardized mean difference <10). CE patients demonstrated a longer length of stay (LOS) in the hospital (median days: 22 vs. 18; p<0.0001) and acute rehabilitation (26 vs. 21; p<0.0001). CE patients were more likely to be hospitalized at one-year follow-up (39% vs. 25%; p<0.0001) for reasons other than cranioplasty including seizures (12% vs 8%; p<0.0001), neurologic events (i.e. hydrocephalus) (9% vs. 4%; p<0.0001), and infections (10% vs 6%; p<0.0001). CE patients were significantly more impaired on the Extended Glasgow Outcome Scale, required more supervision, and were less likely to be employed or living at home at one-year post-injury. No difference was observed in Satisfaction with Life Scale (SWL) scores at one-year. Kaplan Meier estimates for mortality at one- and two-year follow-up showed no difference between CE and CO groups (hazard ratio: 0.57; p=0.4).

Conclusions: Patients who underwent CE versus CO after TBI had longer LOS, decreased functional status, and more rehospitalizations. Survival at two years and SWL scores remained similar. CE for TBI is associated with worse functional outcomes.

Patient Care: This research demonstrates differences in long-term functional and quality of life outcomes for patients with TBI after craniectomy versus craniotomy. The findings in this study will better inform surgical decision-making and prognostication for TBI patients.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of long term functional and quality of life outcomes for patients with TBI after craniectomy versus craniotomy. 2) Discuss, in small groups, how these differences in outcomes influence surgical decision-making and prognostication. 3) Identify an effective surgical treatment for patients with traumatic brain injury that accounts for functional and quality of life outcomes.

References: 1. Kolias, A.G., P.J. Kirkpatrick, and P.J. Hutchinson, Decompressive craniectomy: past, present and future. Nat Rev Neurol, 2013. 9(7): p. 405-15. 2. Kolias, A.G., et al., Surgical management of acute subdural haematomas: current practice patterns in the United Kingdom and the Republic of Ireland. Br J Neurosurg, 2013. 27(3): p. 330-3. 3. Kolias, A.G., et al., Decompressive craniectomy for acute subdural hematomas. J Neurosurg, 2014. 120(5): p. 1247-9; author reply 1249. 4. Hartings, J.A., et al., Surgical management of traumatic brain injury: a comparative-effectiveness study of 2 centers. J Neurosurg, 2014. 120(2): p. 434-46. 5. Bullock, M.R., et al., Surgical management of acute subdural hematomas. Neurosurgery, 2006. 58(3 Suppl): p. S16-24; discussion Si-iv.