Objective: To determine the association between neurosurgical intervention (NSI) rates-defined as craniectomy or craniotomy, across trauma centers 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 GCS score. However, significant variability exists in how trauma centers (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 ACS-TQIP. We included adult trauma patients with SDH >10 mm. Patients with penetrating injuries, non-survivable 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 rate of favorable discharge. Multivariable regression (MR) 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-AIS 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 MR 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 to LV TCs.

Conclusions: More than half of the patients with traumatic SDH >10 mm did not receive NSI as per BTF guidelines. Standardized NSI protocols are needed to improve adherence and outcomes. Methods: Level III.