Association Between Operative Neurosurgical Intervention and Favorable Discharge Among Patients With Traumatic Subdural Hematoma and Poor Neurological Examination.

Abstract

Background and objectives: Patients with traumatic subdural hematoma (SDH) and poor neurological presentation frequently experience adverse outcomes. Few studies investigate whether operative neurosurgical intervention is associated with favorable outcomes for these patients. The objective of this study was to measure associations between operative neurosurgery and favorable discharge in patients with traumatic SDH and poor neurological presentation.

Methods: This was a retrospective cohort study using the American College of Surgeons Trauma Quality Programs Dataset. In total, 13 393 adult patients (≥18 years) presenting with traumatic SDH, midline shift >5 mm, and Glasgow Coma Scale ≤8 were included. Risk-adjusted hierarchical regression models were specified to measure associations between operative neurosurgery and favorable discharge to home or inpatient rehabilitation. Effect modification by pupillary response (both [2R], one [1R] or neither reactive [0R]) was evaluated. Marginal effects of operative neurosurgery on favorable discharge probability were estimated across pupillary response and age subgroups.

Results: Patients with 0R pupils were least likely to undergo operative neurosurgery (0R, 34% vs 1R, 50% vs 2R, 50%; P < .001). After risk adjustment, operative neurosurgery was associated with favorable discharge (odds ratio, 1.93; 95% CI, 1.74-2.14). This association was significantly modified by pupillary response (P for interaction, <0.001), with the greatest potential benefit observed for patients with 0R pupils (probability, 3.7% increased to 11.8%). Operative neurosurgery provided potential benefit across all age quartiles but declined significantly for the eldest patients (>75 years).

Conclusion: Operative neurosurgical intervention is associated with favorable discharge among patients with traumatic SDH and poor neurological presentation. This was consistent across pupillary response and age subgroups, but potential benefit was reduced among the eldest patients.