Experts Call For Lifelong Care After Brain And Spinal Injuries

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An international group of experts is calling for traumatic brain and spinal cord injuries in adults to be treated as conditions that can carry long-term, multisystem health risks. Their Lancet Neurology policy paper proposes coordinated follow-up, scheduled screenings and care navigators, but the pathway still needs testing and implementation across health systems.

An international group of experts is urging health systems to provide long-term, coordinated care after traumatic brain injury (TBI) and spinal cord injury (SCI), arguing that health risks can continue or emerge years after acute treatment ends. In a policy paper published in The Lancet Neurology, the authors propose routine multisystem follow-up, screening and links to specialist care for adult survivors.

The paper, titled “Reframing traumatic brain injury and spinal cord injury as chronic multisystem disorders: toward integrated, long-term care,” describes a proposed shift in how these injuries are managed. The authors say the effects can extend beyond the brain or spinal cord, involving cardiovascular, metabolic, endocrine, neurological and psychiatric health, as well as day-to-day functioning.

To develop their recommendations, the authors searched databases for English-language studies published from 2020 to 2026, focusing on prospective research into long-term outcomes after TBI or SCI. They also consulted international experts and stakeholders, then combined the evidence with chronic-care models used in areas such as stroke, diabetes and cancer survivorship.

The proposed pathway is prevention-first and tiered, ranging from a core package for settings with limited resources to more intensive multidisciplinary care. Suggested components include care navigators, scheduled multisystem screenings, telehealth and direct links to specialist services. The authors also outline seven implementation priorities covering policy, clinical services, workforce development, equity and the economic evidence needed to support changes.

Why Follow-Up Could Change

The recommendations address a gap the authors identify between the long-term risks faced by survivors and the episodic care many receive after leaving acute treatment and rehabilitation. They say surveillance is often fragmented or absent, meaning later complications may go unnoticed until they contribute to hospitalization, loss of function or other harm.

For patients and families, a reliable follow-up plan could provide clearer information about possible health risks and a point of contact for questions or referrals. The authors say some later complications may be preventable, but the paper does not establish that its proposed pathway has already reduced illness or improved outcomes. Its significance is that it translates evidence of long-term risk into a care blueprint that health systems could test and adapt.

From Injury Evidence to Care Plans

The paper builds on research by the authors and other teams examining health outcomes after neurotrauma. The report describes cohort studies published in JAMA Network Open in 2022, 2024 and 2025 that found higher rates of new cardiovascular, endocrine, neurological and psychiatric conditions among survivors. Those studies helped characterize the range of reported long-term risks; the new paper focuses on how care might respond.

The authors describe TBI and SCI as acute-onset, multisystem chronic-risk conditions. That framing does not mean every survivor will develop later complications. Rather, it supports follow-up that can identify individual needs over time instead of assuming medical risk ends when acute care or rehabilitation is complete.

The authors say the model can be adapted to different resource levels. Possible starting points in lower-resource settings include a minimum dataset, community health workers, mobile health tools and teleconsultation. More complex cases could require multidisciplinary services, including rehabilitation and links to stroke, memory, psychiatric or epilepsy care.

“Recovery and medical risk do not end at discharge.”

— The paper’s authors

What the Proposed Pathway Still Needs

The paper presents a policy framework, not results from a trial showing that the proposed pathway works. The source material does not establish which screening schedule or care package would produce the greatest benefit, how much the model would cost, or how it should be funded in different health systems. The authors identify economic evidence and implementation work as priorities.

It is also unclear how risks vary among individual survivors and which patients would benefit most from particular interventions. The authors say they plan to combine longitudinal clinical information with multiomic data to investigate differences in risk profiles. They then plan to tailor prevention and prospectively test the proposed pathways and interventions.

Testing Long-Term Care in Practice

The authors’ next research step is to better characterize people living with TBI by combining longitudinal clinical data and multiomic data. They say this could help explain why some people develop particular complications and support the identification of distinct risk profiles.

They plan to use that work to tailor prevention and prospectively test the care pathways and interventions described in the paper. Until those tests are reported, the recommendations remain a proposed blueprint; the paper does not specify a timeline for trials or when health systems might adopt the model.

Key Questions

What does the new paper recommend?

It proposes coordinated, long-term follow-up after adult traumatic brain or spinal cord injury, including scheduled multisystem screening, care navigation, telehealth and links to specialist services.

Does the paper say every survivor will develop later health problems?

No. The authors describe increased and varied long-term risks, but the framework does not mean that every person will develop complications. The paper argues for follow-up that can identify individual needs over time.

Has the proposed care pathway been shown to improve outcomes?

Not in the source material. The paper sets out a care blueprint; the authors say prospective testing of the proposed pathways and interventions is planned.

What happens after the paper?

The authors plan research combining longitudinal clinical information with multiomic data to study differences in long-term risk, followed by work to tailor prevention and test the proposed care approach.

Source: rss