Primary decompressive craniectomy is associated with worse neurological outcome in patients with traumatic brain injury requiring acute surgery

BACKGROUND The role of decompressive craniectomy in treating raised intracranial pressure (ICP) after traumatic brain injuries (TBI) is controversial. The aim of this study was to assess the differences in prognosis of patients initially treated by decompressive craniectomy, craniotomy, or conservatively. METHODS We conducted a single-center retrospective study on adult blunt TBI patients admitted to a neurosurgical intensive care unit during 2009-2012. Patients were divided into three groups based on their initial treatment - decompressive craniectomy, craniotomy, and conservative. Primary outcome was 6-month Glasgow Outcome Scale (GOS) dichotomized to favorable outcome (independent) and unfavorable outcome (dependent). The association between initial treatment and outcome was assessed using a logistic regression model adjusting for case-mix using known predictors of outcome. RESULTS Of the 822 included patients, 58 patients were in the craniectomy group, 401 patients in the craniotomy group, and 363 patients in the conservatively treated group. Overall, 6-month unfavorable outcome was 48%. After adjusting for case-mix, patients in the decompressive craniectomy group had a statistical significantly higher risk for poor neurological outcome compared to patients in the conservative group (OR 3.06, 95% CI 1.45-6.42) and craniotomy group (OR 3.61, 95% CI 1.74-7.51). CONCLUSION In conclusion, patients requiring primary decompressive craniectomy had a higher risk for poor neurological outcome compared to patients undergoing craniotomy or were conservatively treated. It is plausible that the poor prognosis is related to the TBI severity itself rather than the intervention. Further prospective randomized trials are required to establish the role of decompressive craniectomy in the treatment of patients with TBI.