Surgical Versus Medical Management in Older Adults with Traumatic Brain Injury: A Systematic Review and Meta-analysis
In brief
Surgery reduces 6-month death risk by one-third in older TBI patients
A meta-analysis of 16 cohort studies (132,823 patients at least 60 years) found that operative treatment lowered six-month mortality by roughly 30% but did not improve neurological recovery at discharge or up to one year, and it added about six extra hospital days. The evidence is heterogeneous and low certainty, so decisions must balance longer survival against limited functional gain.
- Journal
- Neurocritical care (Q1)
- Published
- 3 August 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Luis E Cueva-Cañola, Andrea C Beltrán-De la Fuente, Mael S Ayala-Alban, Sergio Morales Acosta, Astrid G Carrión-Cuéllar, Olga N Polania-Pérez, et al.
- PMID
- 42547673
- DOI
- 10.1007/s12028-026-02593-1
Why clinicians should know about it
- Picked for Critical Care and Intensive Care Medicine (top studies of the week, 9 August 2026): High-quality evidence in a top journal
- Picked for Epidemiology (top studies of the week, 9 August 2026).
- Picked for Neurology (clinical) (top studies of the week, 9 August 2026).
- Picked for Neurosurgery (top studies of the week, 9 August 2026).
- Picked for Surgery (top studies of the week, 9 August 2026): Systematic review comparing surgical vs medical management of TBI in
Abstract
BACKGROUND: Traumatic brain injury (TBI) in older adults is associated with high mortality and poor functional outcomes. However, optimal management remains uncertain, as evidence comparing surgical and medical strategies is limited, heterogeneous, and extrapolated from younger populations. We conducted a systematic review and meta-analysis to compare outcomes between surgical and medical management in this population. METHODS: PubMed, Embase, and Web of Science were searched from database inception to 8 December 2025. Studies including adults aged ≥ 60 years with TBI comparing surgical versus medical management were included. The primary outcome was favorable neurological outcome, while secondary outcomes included hospital length of stay (LOS) and mortality. Pooled estimates were calculated as risk ratios (RR) and mean differences (MD) using random-effects models with restricted maximum likelihood and Hartung-Knapp adjustment. RESULTS: A total of 16 cohort studies comprising 132,823 patients were included. Surgical management was not associated with improved favorable neurological outcomes at discharge, 3, 6, or 12 months. However, it was associated with longer LOS (MD = 6.35 days, 95% CI: 2.55 to 10.14; p < 0.01). No differences were observed in in-hospital, 30-day, 3-month, 12-month, or 24-month mortality. Notably, surgical management was associated with a reduction in 6-month mortality (RR = 0.68, 95% CI: 0.51-0.92; p = 0.02). CONCLUSIONS: In older adults with TBI, surgical management was associated with reduced 6-month mortality and longer hospital LOS, but not with improved functional outcomes, highlighting a dissociation between survival and recovery. This dissociation has important implications for clinical decision-making and patient and family counseling. Although this study represents the best available comparative evidence to date on surgical versus nonsurgical management in older adults with TBI, the findings should be interpreted with caution due to substantial heterogeneity and the low to very low certainty of the evidence. High-quality randomized controlled trials are needed to better define the role of surgery in this population. Trial Registration This systematic review and meta-analysis was prospectively registered in PROSPERO on November 21, 2025 (CRD420251236960).
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.