Comparing Direct and Indirect Transfer Pathways for Pediatric Traumatic Brain Injury: Insights from a UK Specialist Neuroscience Center

Optimal transfer strategies for pediatric traumatic brain injury remain debated: direct transfer to a specialist neuroscience center expedites access to neurosurgical care, whereas indirect transfer via a trauma unit allows initial stabilization before secondary transfer. We retrospectively analyzed 375 pediatric traumatic brain injury admissions managed under United Kingdom national guidelines (2019-2024): 184 (49%) were transferred directly to a specialist neuroscience center and 191 (51%) were initially transported to a trauma unit before secondary transfer. Outcomes were assessed using the Pediatric Glasgow Outcome Scale-Extended. The primary outcome was good recovery (upper or lower good); secondary outcomes were time to neurosurgical care, length of stay, complications, and mortality. Propensity score matching and generalized linear models were used to adjust for confounding, with a sensitivity analysis including patients with more than 30 days of follow-up. Protocol fidelity for triage to direct or indirect transfer was 95.2%. Before matching, patients in the direct transfer group were older and had more severe clinical features. In the matched cohort (156 direct, 176 indirect), 81.6% were managed conservatively. Although not statistically significant, follow-up duration was longer in the direct transfer group. Good recovery occurred in 79% of the direct group and 80% of the indirect group, with no significant association between transfer pathway and good recovery (adjusted odds ratio 1.02, 95% confidence interval 0.57-1.86). Times from injury to CT scan, neurosurgical referral, and neurosurgical intervention were significantly shorter in the direct transfer group (all p < 0.05). No between-group differences were observed in length of stay, inpatient or long-term complications, or mortality. The sensitivity analysis yielded concordant findings. Direct transfer shortened the time to neurosurgical care, but within the detectable effect size of this study, no pathway-related difference in clinical outcomes was demonstrated.