Surgical management of patients with combined traumatic brain and spinal cord injury

Background. Combined traumatic brain injury and spinal cord injury (TBI/SCI) is one of the most challenging cases in emergency neurosurgery. The severity of systemic injury, frequent extracranial lesions, impaired consciousness, and the necessity of stepwise treatment complicate timely diagnosis and worsen surgical outcomes.

Aim. To assess clinical features, diagnostic aspects, and surgical treatment outcomes in patients with combined TBI/SCI.

Materials and methods. A retrospective analysis of 1,772 patients with traumatic brain injury (TBI), spinal cord injury (SCI), and their combination (TBI/SCI) who were admitted and surgically treated between 2016 and 2022 at the Sklifosovsky Research Institute for Emergency Medicine, City Clinical Hospital No. 3 named after S.M. Kirov, and Alexander-Mariinsky Regional Clinical Hospital was performed. The study group included 63 patients with combined TBI/SCI, while the comparison groups were comprised of 1,519 patients with isolated TBI and 190 patients with isolated SCI. The mechanism of injury, time to admission and diagnosis, Injury Severity Score (ISS), Glasgow Coma Scale score, neurological deficit according to the American Spinal Injury Association (ASIA) scale, timing and extent of surgery, and treatment outcomes were evaluated. Statistical analysis included non-parametric tests, χ² and Fisher’s exact tests, and Spearman correlation analysis.

Results. Combined TBI/SCI was diagnosed in 3.6 % of patients and was associated with the highest injury severity, with median ISS of 34.0 [25; 40.5]. High-energy trauma mechanisms predominated, including road traffic accidents (46.0 %) and falls from height (44.4 %). This group was characterized by a high rate of multiple associated injuries (42.9 %), predominance of cervical spine fractures (33.3 %) and multilevel injuries (30.2 %), and impaired consciousness on admission in 69.8 % of cases. Severe spinal cord injury (ASIA A–B) was observed in 19.0 % of patients. Delayed verification of spinal injury for more than 6 hours occurred in 42.9 % of cases. The median time from admission to surgery was 72 [7; 312] hours, exceeding that in isolated TBI and isolated SCI. Early spinal surgery (≤24 h) was associated with a higher rate of neurological improvement on the ASIA scale than delayed surgery performed after 72 hours (21.4 % vs 6.5 %).

Conclusion. Combined TBI/SCI should be considered a distinct severe trauma type associated with high frequency of cervical and multilevel spinal injuries, impaired consciousness, and diagnostic delays. Improved outcomes require early whole-spine CT assessment in patients with decreased consciousness, multidisciplinary treatment strategy, and the earliest possible spinal decompression and stabilization once life-threatening conditions are under control. 

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