How Volume of Neurosurgical Interventions Impacts Patient Outcomes

Objective: To determine the association between neurosurgical intervention (NSI) rates-defined as craniectomy or craniotomy, across trauma centers (TCs) and patient outcomes in traumatic subdural hematoma (SDH). Background: The Brain Trauma Foundation guidelines recommend urgent surgical evacuation for acute SDH with a thickness >10 mm, regardless of the patient’s Glasgow Coma Scale score. However, significant variability exists in how TCs manage these cases, and the impact of such differences on patient outcomes remains unclear. Methods: A 5-year (2017–2021) retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program. We included adult trauma patients with SDH >10 mm. Patients with penetrating injuries, nonsurvivable trauma, advance directives limiting care, or ED death were excluded. TCs were stratified into tertiles based on the NSI volume as low, middle, and high volume TCs. Outcomes measured were in-hospital mortality and the rate of favorable discharge. Multivariable regression analyses were used to assess the independent effect of increasing TC neurosurgical volume on outcomes. Results: Of 67,324 adult trauma patients with traumatic SDH >10 mm, 45.5% underwent NSI across 293 TCs. The median ISS and head-abbreviated injury severity were 21 and 4, respectively. Greater neurosurgical volume was associated with lower rates of in-hospital mortality and higher rates of favorable discharge ( P <0.001). On multivariable regression analysis, patients undergoing NSI at HV TCs were 23% less likely to die and 53% more likely to be discharged to home or rehabilitation compared with low-volume TCs. Conclusions: More than half of the patients with traumatic SDH >10 mm did not receive NSI as per Brain Trauma Foundation guidelines. Standardized NSI protocols are needed to improve adherence and outcomes. Level of Evidence: Level III.