Enhanced Recovery Protocol Post-TBI (ERA-TBI): Factors Determining Morbidity and Mortality

Why clinicians should know about it

• Picked for Neurosurgery (paper of the day, 27 July 2026).

Abstract

Traumatic brain injury (TBI) remains a leading cause of death and long-term disability worldwide, with substantial heterogeneity in recovery trajectories despite advances in acute neurocritical care. Enhanced Recovery After Surgery (ERAS) programmes, which integrate evidence-based, multidisciplinary perioperative care bundles, have demonstrated consistent benefits across multiple surgical specialities and emerging promise in neurosurgical populations. However, the application of enhanced recovery principles to the recovery phase following TBI remains fragmented and insufficiently synthesised. This narrative review examines recovery-phase factors influencing morbidity and mortality after TBI within the conceptual framework of Enhanced Recovery After TBI (ERA-TBI). Focussing specifically on postacute recovery, we synthesise evidence across three interrelated domains: rehabilitation strategies, patient demographics and preexisting conditions. Perioperative surgical techniques and acute intensive care management are considered only insofar as they contextualise recovery-phase outcomes. The reviewed literature demonstrates that early, intensive and multidisciplinary rehabilitation, particularly early mobilisation and structured cognitive or neuropsychological interventions, is associated with improved neurological recovery, functional independence, quality of life and reduced hospital length of stay, without evidence of increased mortality. Emerging technologies, including virtual reality and telerehabilitation, show promising cognitive and functional benefits, although evidence remains limited by heterogeneity and small sample sizes. Patient-level factors strongly modify recovery potential: advanced age, frailty and socioeconomic disadvantage consistently predict poorer outcomes, while access to high-intensity inpatient rehabilitation is a key mediator of morbidity. Preexisting metabolic, cardiovascular and neuropsychiatric comorbidities further exacerbate secondary brain injury, prolong hospitalisation and increase postdischarge mortality risk. Overall, ERA-TBI pathways must move beyond uniform care bundles towards stratified, patient-centred recovery models that integrate biological reserve, social context and comorbidity burden. Standardising the recovery phase through an ERA-TBI framework offers a critical opportunity to reduce variability in outcomes, optimise functional recovery and address the growing global burden of TBI-related disability.

Abstract as published, via PubMed.