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How Volume of Neurosurgical Interventions Impacts Patient Outcomes: An Analysis of 30,000 Craniectomies and Craniotomies
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Louis Magnotti, *Muhammad Haris Khurshid, *Adam Nelson, *Omar Hejazi, *Tanya Anand, *Francisco Castillo Diaz, *Lourdes Castanon, *Mohammad Al Ma'ani, *Michael Ditillo, Bellal Joseph
University of Arizona, Tucson, AZ
Objectives: The Brain Trauma Foundation recommends emergent surgical evacuation for subdural hematoma (SDH) with a thickness >10mm, regardless of the patient’s GCS score. Variability exists in how trauma centers manage these cases, and the impact of this variation on patient outcomes is not well understood. The aim of this study was to identify the association between neurosurgical intervention (NSI) defined as craniectomy or craniotomy rates and outcomes in patients with traumatic SDH. We hypothesize that higher NSI rates for patients with SDH>10mm are associated with improved patient outcomes.
Methods: We performed a 5 year (2017-2021) retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program. We included adult (age ?18 years) trauma patients presenting with SDH >10mm. Patients with penetrating injuries, non-survivable trauma (body region AIS=6), advance directives limiting care, or ED death were excluded. Using facility key identifiers, trauma centers (TCs) were stratified into tertiles based on the NSI rates as low [LV], middle [MV], and high [HV] volume TCs. Primary outcome was in-hospital mortality. Secondary outcome was favorable discharge. Multivariable regression analyses were performed to assess the independent effect of increasing neurosurgical volume on outcomes.
Results: A total of 67,324 adult trauma patients with traumatic SDH >10mm were managed at 771 TCs. The mean (SD) age was 66 (18) and 66% were male. On presentation, the median [IQR] GCS was 14[4-15]. Fall was the most common (75%) injury mechanism. The median [IQR] ISS and head-AIS were 25 [16-26] and 4 [4-5] respectively. NSI was performed in 46% (n= 30,620) cases across 293 TCs (LV:182, MV:65, HV:46). TC with the highest neurosurgical volume performed 641 cases. Greater neurosurgical volume was associated with lower rates of in-hospital mortality (LV:44% vs MV:43% vs HV:41%, p=0.003) and higher rates of favorable discharge (LV:5% vs MV:5.3% vs HV:7.6%, p<0.001). On multivariable regression analysis, after adjusting for demographics, GCS, ISS, head-AIS, preinjury anticoagulant use & blood product requirements, patients with traumatic SDH >10 mm treated at HV TCs were 20% less likely to die and 64% more likely to have favorable discharge compared to LV TCs (
Table).
Conclusion: More than half of patients with traumatic SDH with more than 10 mm do not follow the BTF guidelines. Higher neurosurgical intervention volume at trauma centers is associated with better outcomes for subdural, as shown by lower mortality and higher favorable discharge rates. These findings highlight that variations in surgical volume are driven by center-specific practices, underscoring the need for standardizing protocols for patients with traumatic intracranial hematomas.
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