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An international expert group writing in The Lancet Neurology proposes treating adult traumatic brain injury and spinal cord injury as chronic, multisystem conditions that can require care well beyond rehabilitation. Its proposed pathway includes scheduled screening, care navigators and links to specialist services, but the paper sets out a blueprint rather than evidence that the model has already improved outcomes.
An international group of experts is calling for long-term, coordinated care for adults with traumatic brain injury (TBI) or spinal cord injury (SCI), arguing that health risks can persist or emerge years after acute treatment ends. In a paper published in The Lancet Neurology, the authors propose treating the injuries as chronic multisystem conditions and outline a prevention-focused care pathway; the paper offers a framework, not proof that a particular program has improved patient outcomes.
The authors say survivors may develop cardiovascular, metabolic, endocrine, neurological, psychiatric and functional complications after the initial injury. Some problems may continue over time, while others can appear later. Yet, according to the paper, follow-up is often fragmented or absent after patients leave acute care and rehabilitation, leaving some complications undetected until they lead to hospitalization, functional decline or other harm.
To develop their proposal, the researchers searched multiple 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 and drew on chronic-care models used for conditions such as stroke, diabetes and cancer survivorship.
The proposed pathway includes scheduled multisystem screenings, neurotrauma care navigators, telehealth-supported follow-up and direct connections to specialist services. The paper also identifies implementation priorities across health policy, clinical care, workforce development and equity, and calls for economic evidence to support lasting changes. The authors propose a tiered approach, ranging from a basic package in settings with limited resources to multidisciplinary care for people with more complex needs.
Care After Discharge Needs Continuity
The proposal challenges a care pattern in which treatment and monitoring can wind down after acute care and rehabilitation, even though medical risks may continue beyond discharge. For patients and families, a regular point of contact and clear information about possible late complications could help them seek assessment and understand why follow-up screening is recommended.
If adopted and tested, coordinated follow-up could also help health systems identify emerging problems earlier and connect survivors with relevant services. The authors say the pathway is intended to work across different resource levels, including through community health workers, mobile health tools and teleconsultation where specialist care is harder to access. These are proposed benefits; the paper does not report that the blueprint has already reduced complications or hospitalizations.
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Evidence Behind the New Framework
The paper builds on earlier research by authors including Saef Izzy and Sandro Marini and their colleagues. The source report describes cohort analyses published in JAMA Network Open in 2022, 2024 and 2025 that found higher rates of new cardiovascular, endocrine, neurological and psychiatric conditions among survivors of TBI and SCI. Those studies helped characterize longer-term risks; the new paper seeks to turn that evidence into a proposed care model.
The authors describe changes after neurotrauma as potentially biological, behavioral and social, and say they may persist for years or decades. They cite chronic inflammation, accelerated biological aging and cardiometabolic risk among areas of concern. The proposal applies to adult TBI and SCI and is framed as a shift from episodic support toward ongoing, coordinated attention to health across multiple systems.
“Recovery and medical risk do not end at discharge.”
— The paper’s authors
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Implementation and Outcomes Remain Open
The paper presents a care blueprint, but the source material does not report prospective testing of the proposed pathway or show whether it improves health outcomes. It is also not yet clear how health systems would fund and staff the model, which screening schedules would be appropriate for different patients, or how consistently services could be connected across regions.
The authors identify payment reform, longitudinal registries, workforce development and economic evidence as implementation priorities. Further research is needed to clarify which survivors face which risks, when complications are most likely to arise and which elements of follow-up provide the greatest benefit. The authors’ proposed approach should not be read as a claim that all survivors will develop later complications.
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Research to Test Tailored Follow-Up
The authors say their next research step is to combine longitudinal clinical information with multiomic data to characterize people living with TBI and identify profiles linked to particular long-term complications. They plan to use that work to tailor prevention and to prospectively test the care pathways and interventions proposed in the paper.
Those studies would help determine whether the framework can be delivered in practice and whether it improves detection, access to care or patient outcomes. Until such testing is reported, the paper’s recommendations remain a proposed direction for clinical practice and health policy rather than a validated standard of care.
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Key Questions
What does the paper recommend after a brain or spinal cord injury?
It proposes coordinated follow-up that may include scheduled screening across health systems, a care navigator, telehealth support and links to specialist services. The specific plan would depend on patient needs and available resources.
Does the paper show that lifelong care improves outcomes?
No. It sets out a proposed framework based on existing evidence and expert consultation. The authors say the proposed care pathways and interventions still need to be prospectively tested.
What long-term health issues are discussed?
The paper describes possible cardiovascular, metabolic, endocrine, neurological, psychiatric and functional complications. It does not say every survivor will experience these conditions; individual risks and outcomes can vary.
What research do the authors plan next?
They plan to combine long-term clinical records with multiomic data to study differences in risk profiles, then use those findings to tailor prevention and test care pathways.
Source: rss
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