Can glasgow score at discharge represent final outcome in severe head injury?

BACKGROUND: Patients with head injury continue to improve over time and a minimum follow-up of six months is considered necessary to evaluate outcome. However, this may be difficult to assess due to lack of follow-up. It is also well known that operated patients who return for cranioplasty usually have the best outcome. AIMS AND OBJECTIVES: To assess the outcome following severe head injury using cranioplasty as a surrogate marker for good outcome. MATERIALS AND METHODS: This was a retrospective study carried out from January 2009 to December 2010. All patients with severe head injury who underwent decompressive craniectomy (DC) in the study period were included. Patients who came back for cranioplasty in the same period were also included. Case records, imaging and follow up visit data from all patients were reviewed. Glasgow Coma Score (GCS) on admission and Glasgow Outcome Score (GOS) at discharge were assessed. OBSERVATIONS AND RESULTS: Of the 273 patients, 84.25% (n=230) were males and 15.75% (n= 43) were females. The mean age was 34.3 years (range 2-81 years, SD 16.817). The mean GCS on admission was 5.615 (range 3-8, SD 1.438). The in-hospital mortality was 54% (n=149). Good outcome (GOS of 4 or 5) at discharge was attained in 22% (n=60) patients. Sixty five patients returned for cranioplasty (with a GOS of 4 or 5) during the study period. There was no statistical difference in the number of patients discharged with good outcome and those coming back for cranioplasty in the study period (P>0.5). Patients who came back for cranioplasty were younger in age (mean age 28.815 years SD 13.396) with better admission GCS prior to DC (mean GCS 6.32 SD1.39). CONCLUSIONS: In operated severe head injury patients significant number of patients (24% in our study) have excellent outcome. However, insignificant number of patients had further improvement to GOS 4 or 5 (good outcome) from the time of initial discharge. This suggests that due to lack of intensive rehabilitative facilities, GOS at discharge may be representative of final outcome in the vast majority of cases of severe head injury in developing countries like India