Surgical Versus Medical Management for Severe Pediatric Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

Abstract

Decompressive craniectomy (DC) is used to control intracranial pressure in severe pediatric traumatic brain injury (TBI), although evidence of its benefit in pediatric patients remains conflicted. To address this, this meta-analysis evaluates the outcomes of DC vs medical management (MM) in pediatric severe TBI. Following PRISMA guidelines, databases were searched through October 2025 for studies comparing DC and MM in patients younger than 18 years with severe TBI. Randomized control trials and prospective and retrospective studies reporting at least one clinical outcome were included. Random-effects models were applied, with relative risks used for dichotomous outcomes and mean differences for continuous outcomes. Our analysis included 553 DC and 2336 MM patients, with 1 randomized trial and 10 observational studies. Pooled analyses showed no significant difference in good functional outcomes between DC and MM, whether based on the Glasgow Outcome Scale or study-specific definitions or mortality (1.06, 95% CI 0.69-1.64; P = .78). Subgroup analyses of Glasgow Outcome Scale scores at discharge and 30 days corroborated these findings. DC was associated with a significantly longer intensive care unit stay (mean differences, 6.2 days, 95% CI 4.4-8.0; P < .001) and a similar trend toward longer hospital stay (mean differences, 4.0 days, 95% CI -0.6 to 8.7; P = .09), which became significant on sensitivity analysis. Reported complication rates, when reported, were low and comparable across groups. In children with severe TBI, DC does not appear to provide clear survival or functional advantages over MM and is significantly associated with longer intensive care unit and hospital stays. However, these findings should be interpreted with caution as the current literature mainly composed of small and heterogeneous retrospective studies. Further large, prospective, multicenter studies are needed to confirm these findings, refine surgical indications, and establish pediatric-specific management guidelines.