Surgical intervention and patient factors associated with poor outcomes in patients with traumatic brain injury at a tertiary care hospital in Uganda

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  • 1 Duke University Division of Global Neurosurgery and Neurology, Durham;
  • 3 Department of Neurology,
  • 2 Duke University School of Medicine, Durham, North Carolina;
  • 4 Department of Neurosurgery, Mulago Hospital, Kampala, Uganda;
  • 5 Department of Neurosurgery, Duke University Medical Center, Durham;
  • 6 Duke University Global Health Institute, Durham;
  • 7 Duke Forge, Duke University School of Medicine, Durham; and
  • 8 Department of Statistical Science, Duke University, Durham, North Carolina
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OBJECTIVE

The purpose of this study was to investigate whether neurosurgical intervention for traumatic brain injury (TBI) is associated with reduced risks of death and clinical deterioration in a low-income country with a relatively high neurosurgical capacity. The authors further aimed to assess whether the association between surgical intervention and acute poor outcomes differs according to TBI severity and various patient factors.

METHODS

Using TBI registry data collected from a national referral hospital in Uganda between July 2016 and April 2020, the authors performed Cox regression analyses of poor outcomes in admitted patients who did and did not undergo surgery for TBI, with surgery as a time-varying treatment variable. Patients were further stratified by TBI severity using the admission Glasgow Coma Scale (GCS) score: mild TBI (mTBI; GCS scores 13–15), moderate TBI (moTBI; GCS scores 9–12), and severe TBI (sTBI; GCS scores 3–8). Poor outcomes constituted Glasgow Outcome Scale scores 2–3, deterioration in TBI severity between admission and discharge (e.g., mTBI to sTBI), and death. Several clinical and demographic variables were included as covariates. Patients were observed for outcomes from admission through hospital day 10.

RESULTS

Of 1544 patients included in the cohort, 369 (24%) had undergone surgery. Rates of poor outcomes were 4% (n = 13) for surgical patients and 12% (n = 144) among nonsurgical patients (n = 1175). Surgery was associated with a 59% reduction in the hazard for a poor outcome (HR 0.41, 95% CI 0.23–0.72). Age, pupillary nonreactivity, fall injury, and TBI severity at admission were significant covariates. In models stratifying by TBI severity at admission, patients with mTBI had an 80% reduction in the hazard for a poor outcome with surgery (HR 0.20, 95% CI 0.04–0.90), whereas those with sTBI had a 65% reduction (HR 0.35, 95% CI 0.14–0.89). Patients with moTBI had a statistically nonsignificant 56% reduction in hazard (HR 0.44, 95% CI 0.17–1.17).

CONCLUSIONS

In this setting, the association between surgery and rates of poor outcomes varied with TBI severity and was influenced by several factors. Patients presenting with mTBI had the greatest reduction in the hazard for a poor outcome, followed by those presenting with sTBI. However, patients with moTBI had a nonsignificant reduction in the hazard, indicating greater variability in outcomes and underscoring the need for closer monitoring of this population. These results highlight the importance of accurate, timely clinical evaluation throughout a patient’s admission and can inform decisions about whether and when to perform surgery for TBI when resources are limited.

ABBREVIATIONS GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; HD = hospital day; HIC = high-income country; HR = hazard ratio; ICP = intracranial pressure; ICU = intensive care unit; LMICs = low- and/or middle-income countries; MNRH = Mulago National Referral Hospital; MOI = mechanism of injury; moTBI = moderate TBI; mTBI = mild TBI; RTI = road traffic incident; SSA = Sub-Saharan Africa; sTBI = severe TBI; TBI = traumatic brain injury.

Supplementary Materials

    • Supplemental Tables 1—3 (PDF 388 KB)

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Contributor Notes

Correspondence Timothy W. Dunn: Duke University, Durham, NC. timothy.dunn@duke.edu.

INCLUDE WHEN CITING Published online March 26, 2021; DOI: 10.3171/2020.9.JNS201828.

Disclosures Dr. Haglund has received from NuVasive and LifeNet clinical or research support for the study described.

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