Variable Treatment Effects of Cranial Surgery in Pediatric Severe Traumatic Brain Injury

BACKGROUND AND OBJECTIVES: Severe traumatic brain injury (TBI) in children is associated with poor outcomes, but evidence surrounding the role of operative cranial surgery in this patient population is limited. Thus, we sought to evaluate associations between cranial surgery and hospital discharge outcomes among pediatric patients with severe TBI and to identify patient subgroups most likely to benefit. METHODS: This was a retrospective cohort study using data from the Trauma Quality Improvement Program database (2017-2022). Pediatric patients with severe TBI (presenting Glasgow Coma Scale ≤8) were included. Hierarchical regression and propensity score matching investigated associations between open cranial surgery (craniotomy or decompressive craniectomy) and favorable discharge disposition (home or inpatient rehabilitation). A causal forest model was constructed to identify heterogenous treatment effects of cranial surgery across strata of patient baseline and injury characteristics. RESULTS: Among 2705 patients (median age, 13 years), 23% underwent cranial surgery. In both full and propensity score-matched cohorts (N = 998), risk-adjusted hierarchical regression analyses revealed that cranial surgery was associated with greater odds of favorable discharge (matched cohort odds ratio, 1.53; 95% CI, 1.04-2.27; P = .03) and lower odds of inpatient mortality (matched cohort odds ratio, 0.28; 95% CI, 0.18-0.45; P < .001). Causal forest analysis identified younger age, lower presenting Glasgow Coma Scale, higher Injury Severity Score, midline shift >5 mm, and the absence of pupil reactivity as key modifiers of treatment effect, with the greatest estimated benefit observed for patients younger than 12 years and for the most severely injured patients. CONCLUSIONS AND RELEVANCE: Cranial surgery was associated with improved functional and survival outcomes in pediatric severe TBI compared with nonoperative measures, with the largest relative benefit in patients younger than 12 years and those with high-risk clinical features. These findings support operative cranial intervention for selected pediatric patients and may inform refinement of age- and injury-specific operative management guidelines for pediatric severe TBI.