Shari-Lynn

Umlas,

MD

#{149} John

J. Cronan,

MD

Splenic Trauma: Can CT Grading Enable Prediction of Successful Nonsurgical Treatment? The capability of computed tomographic (CT) grading systems to enable prediction of successful nonsurgical treatment of splenic trauma in children and adults was evaluated. Fifty-six patients with documented splenic injury were exammed with CT by use of standard trauma protocols. Each CT scan was graded according to two recently proposed grading Systems. The charts of these patients were then reviewed, and correlations between the CT grade and clinical outcome were determined with each grading system. Forty patients underwent successful nonsurgical treatment; three of these patients (8%) underwent delayed celiotomy for splenic rupture after failure of nonsurgical treatment. Two of these three had grades that indicated nonsurgical treatment was viable. In each of these three patients, splenectomy was necessary. In the 16 patients who underwent surgery, eight cases (50%) of CT grading errors were documented with surgery. In four cases, the extent of the injury was underscored with CT, and in another four cases the injury was overscored. It is still not clear whether the severity of splenic injury as defined with CT correlates with clinical outcome. Index

terms:

Computed

tomography

(CT),

clinical effectiveness (CT), preoperative (CT), utilization 775.1211 . Spleen, 775.41

tomography #{149} Computed tomography #{149} Efficacy study . Spleen, CT, injuries, 775.41 #{149} Trauma,

Radiology

178:481-487

I

From

1991;

the

#{149} Computed

Department

of Diagnostic

Imag-

ing, Rhode Island Hospital. 593 Eddy St. Providence, RI 02902. Received July 16, 1990; revision requested August 14; revision received September 4; accepted September 6. Address reprint requests to J.J.C. c RSNA, 1991

F

nearly 40 years, the role spleen in the body’s defense against infection has been well

of the

OR

known. macken after

In 1952, described that

in five

time,

this

of splenic

children

syndrome

ronto,

ative

for Sick

reported

outcome

Children

a successful

systems

PATIENTS During 1985 and

in Tononoper-

in 12 children trauma and

grading

the

with were level

in an these

might

be

of clinical

METHODS

between January 1989, 1,290 patients

a diagnosis of abdominal trauma treated at Rhode Island Hospital, a I trauma center. Two hundred nine-

ty of these

splenic

with clinical

AND

the period December

5-year

and 1989, whether

used as accurate predictors outcome in splenic injury.

has encouraged clinicians to for effective ways to preserve

Hospital

during

between 1985 to determine

CT-based

of in-

splenic tissue after trauma. Hemisplenectomy, splenonrhaphy, splenic artery ligation, and autotmansplantation have all been used as surgical methods of splenic tissue salvage. In 1968, Upadhyaya and Simpson, at

The

trauma

period attempt

has been documented in asplenic adults as well (2). The occurrence overwhelming postsplenectomy

fection search

goal of this study was to apply the grading systems of Buntain et a! (15) and Resciniti et al (16) to the population of patients admitted to the authors’ institution with the diagnosis

King and Schualtered immunity

splenectomy

(1). Since

Systems

patients

injury.

tients uation

had

documented

Fifty-six

underwent of their

of these

abdominal injuries prior

290 pa-

CT for evalto any surgi-

blunt abdominal signs of splenic injury nonsurgical treatment jury in selected patients

(3). Successful of splenic inhas since

cal intervention. Only patients who were considered hemodynamicaily stable or who were quickly and easily resuscitated

been well populations

in pediatric data suggest-

at admission, ical signs

documented (4-7), and

tion, underwent tial diagnostic patients (52%)

ing success with selected adult patients have been plentiful in recent years (8-12). It has been suggested that celiotomy for delayed rupture the spleen is associated with greater morbidity and mortality and, perhaps, a decreased ability to perform successful splenic salvage procedure than early treatment with surgery

(13,14). Therefore, an accurate od to predict whether or not gical treatment desirable.

In recent

will

years,

computed

(48%)

of

a

is

tomog-

naphy (CT) has been suggested method of assessing the extent splenic trauma in hemodynamically stable patients. Several studies literature (15-18) have proposed ous ways of grading on classifying

were

as a of in the vanin-

jury to the splenic capsule or parenchyma, and some have attempted to correlate these classifications with successful or unsuccessful nonsurgical treatment in their patients. The

and

the adult 13 (45%) 34 male

were without penitoneal

children nine

CT as the Twenty-nine and 27 patients

(under

patients, were

dinirrita-

mi-

abdominal procedure. were adults

Of the pediatric (67%)

methnonsur-

be successful

and who of generalized

age

16 years).

18 were

girls

(33%),

boys and

of

patients, 16 (55%) were men and were women; there was a total of patients (61%) and 22 female pa-

tients (39%). The average age was 9 years in the pediatric group, 42 years in the adult group, and 26 years overall (range, 3-78 years). The mechanisms of injury were motor vehicle accident (n 20), collision between motor vehicle and pedestnian

(n

vehicle (n and

=

13),

and 1), fall assault

were

obtained

tation

of the

collision

between

motor

bicycle

(n = 2), bicycle 13), sports related 2). All initial CT

(n

(n

within

24 hours

patient

in

the

alone

(n

5),

scans

of presen-

emergency

room.

Abbreviation:

DPL

=

diagnostic

peritoneal

lavage.

481

CT Scan Abdomen”

Technique

in “Trauma

Thirty to 60 minutes prior to initiation of scanning, meglumine and sodium diatnizoate (Gastrografin; Squibb Diagnostics/Argon Medical, Princeton, NJ) was administered orally. Most patients had a

large-bone

nasogastnic

tube

already

in

place, and 500 mL of a 2% solution was administered via the tube. If a patient had no tube in place, the contrast material was taken orally. Just prior to scanning, an additionai 200 mL of contrast material was

given

orally.

pulled

back

One

The nasogastric above

hundred

contrast venously the rate

the fifty

tube

was

diaphragm. milliliters

of 60%

material was administered intnaby means of power injection at of 2 mL/sec for 50 seconds and 1

mL/sec for 50 seconds. Scans 10 mm thick were obtained from the dome of the diaphragm through the lower pole of the kidneys at 10-mm increments and from the kidney to the pubic symphysis at 20mm increments. Scan time was programmed to minimize intenscan delay and the time of the entire scan sequence. The CT scans were evaluated with two scoring systems. The scoring system proposed by Buntain et a! (15) is shown in Table 1 . This system uses a ranked vanable scale, supplemented by a nominal yariable scale of qualitative data, to group patients into one of four categories based on the number and severity of capsular and panenchymal splenic injuries. In addition, the system allowed the reader to take into account the existence of other intraon extraabdominal injuries. The second system is that proposed by Resciniti et al (16) (Table 2). This system employs an interval scale that allows the reader to

evaluate

the integrity

of the splenic

nenchyma and the splenic pendently of one another. into account the existence nai on pelvic intnapenitoneal

reader

adds

the scores

from

pa-

capsule indeIt also takes of any abdomifluid. The

each of the

four categories for a total score of 0-6 points. In addition, a provision is made by allowing the reader to award 0.5 points for questionable observations (eg, “possible perisplenic fluid”). The CT scans were reviewed by one of the authors (J.J.C.) without knowledge of any clinical data, treatment decisions, on outcome. The medical records of the 56 patients were subsequently reviewed by

one of the authors

(S.L.U.),

and infonma-

tion was obtained regarding age, sex, mechanism of injury, initial heart rate and blood pressure, initial hematocnit, and the number of units of packed red blood cells transfused during the first 24 hours. Treatment modalities were classified as successful nonsungicai treatment, surgical splenic salvage (splenorrhaphy, hemisplenectomy, splenic artery ligation), tion

or splenectomy. Surgical intervenwas further classified “early” if pen-

formed within 24 hours of the initial evaluation on “late” if performed thereafter. Data obtained with each of the grading

482

Radiology

#{149}

systems was compared with clinical outcome in an effort to assess the ability of these systems to enable accurate prediction of the success on failure of nonsungical treatment. Statistical analysis of the

data, comparing CT evaluation

the relationship between and outcome, was pena x test of independence by

formed with use of the goodness Williams correction

of fit G-test (19,20).

with

the

these

patients

were

successfully

treated without surgery. Of the 16 patients who underwent surgery (early or late) and thus provided documentation of the actual extent of their injuries, eight (50%) had radiologic diagnoses that were classified erroneously with this system (Table 5). Use of this system was found

to have

caused

underscoring

RESULTS Table 3 summarizes the clinical treatment and outcome of the patients in our study. Of the 56 patients in our study, 18 adults and 25 children initially underwent nonsurgical treatment. All 25 children with conservative treatment did well. Three of the 18 adults (ages 44, 70, and 74 years)

who

treatment splenectomy. tients had

underwent

accidents,

nonsurgical

and

all

consisted

of a decreasing

of hemisplenectomy

Injury

Criteria

Ranked

variable scale

Localized capsular disruption or subcapsular hema-

toma, without

significant

parenchymal Class

II

Single

injury

or multiple

and tions,

capsular

panenchymal

disruplongi-

or

transverse

tudinal, that do not extend into the hilum or involve major vessels; intnaparenchynsal hematoma may or may not coexist Deep fractures, single or multiple, transverse or longitudinal, extending into the hilum and involving major blood vessels Completely shattered or

Class III

Class IV

fragmented

spleen

and

splenonrhaphy. Nine adults underwent early celiotomy; of these, six underwent splenic salvage procedunes (splenic artery ligation, hemisplenectomy, splenonrhaphy) and three required total splenectomy. Two adults who underwent exploratory surgical intervention were found to have no injury at all. Only one patient in the study died, and the death was attributed to neunologic injuries. The abdominal CT scans were first evaluated according to the method outlined by Buntain et al (15) (Table 1). This method was used to classify both adult and pediatric cases. Eighteen class I, 23 class II, 10 class III, and two class IV injuries were classified with this method (Table 4). Three additional patients had documented splenic injury but did not fall into any of the categories devised by Buntain et al; these were assigned a class of 0. Of these three patients, one had no signs of splenic injury at mitial CT but subsequently had delayed rupture and nequined emergency splenectomy. Both of the other class 0 patients had negative CT scans at mitial evaluation but wene found to have class I and II injuries, respectively, on follow-up studies. Both of

of Splenic

Splenic

he-

matocrit and syncope in all three patients. Both of the children treated with early celiotomy underwent successful splenic salvage procedures consisting

et al Classification

Injury

were

hemodynamically stable at admission. Clinical signs of delayed ruptune occurred at 2, 5, and 1 1 days aften initial presentation. These clinical signs

1

Buntain

Class I

initially later required All three of these painjuries resulting from mo-

ton vehicle

Table

spleen,

separated

normal

blood

or

from its supply

at

the pedicle Nominal variable scale

A

Without other intraabdominal injury With other associated intraabdominal injury: B1 solid viscus, B2 = hollow

B

viscus

C

With associated minal injury

Table

extraabdo-

2 et al CT Splenic

Reeciniti Region

Evaluation Scone

Splenic parenchyma

0

Intact

1

Laceration

defects) 2 Fracture

(thick,

irregular 3 - Shattered

Splenic

capsule

Abdominal

Pelvic

fluid

fluid Total

(linear

defects)

0

Intact

1

Penisplenic

fluid

present 0 = None 1 = Any intraabdominal intrapenitoneal fluid (except pensplenic fluid) 0 None 1 = Any intnaperitoneal pelvic fluid Sum of parenchymal, capsular, abdominal fluid, and pelvic fluid

scores Questionable

0.5 points

observations

February

1991

in four injuries (25%). In the six patients whose injuries were so severe that salvage was not possible and splenectomy was required, this method caused underscoring of injuries in three tients

(50%). In two of the three who were initially treated

operatively rupture,

and injuries

The

the

scans

were

method (Table adult

also

experienced lower mean

were ovensconed by use of this system, including injuries in two patients who had no injuries whatsoever at lapanotomy. The data obtained with the Buntam et al classification system were evaluated for significance by use of a

eters than

x2

those

2). These patients

and lower mean patients in whom

tomy

was

recommended.

the patients requiring splenectomy early celiotomy had lower mean scones in three of the four parameters as well as lower mean totals than

between CT outcome. The on the necomet al that pa-

patients

who

required

at

splen-

onrhaphy on splenic artery ligation only. Resciniti et al cite a score of 2.5

study,

did

significant

two had Statistical

scores of less comparisons

between

the

class

I and

class

II injuries

II injuries

and

all

pa-

Splenic

versus

Salvage

treatment

in any

patient

2.5.

Of

three

who

tients with class III on IV injuries should undergo early lapanotomy in an effort to maximize splenic salvage. When the G-test of independence with the Williams correction was used for 2 X 2 tables, it was found that CT evaluation with this method and clinical outcome were independent of each other (P > .5).

Table 3 Splenectomy

nonsurgical

fail

the

underwent

underwent

without

in our

celiotomy,

treatment

those

who

ultibecause

rupture

(ie, failed

treatment),

original

who

splenectomy

splenic

as was done A x2 test of intotal CT score

study.

dependence

study

than 2.5 (Fig were made

of patients

nonsungical

the

patients

and

not

below

delayed

subsets

required

of delayed

a score

successful

surgery

mately

in

with

between

Adult

Pediatric

Total

3 3

0 0

3 3

15

25

40

6

2 27

8 54

Splenectomy Eaniy(24h)

Spienic

salvage

Nonoperative treatment Surgical treatment: splenorrhaphy,

SAL,

celiotomy)

27

Total Note.-Two ligation.

additional

adult

patients

were

found

to have

no injury

at celiotomy.

SAL

=

splenic

artery

Table 4 Buntain CT Classification

and Clinical

Successfully

Observed 2 14 16 6 2

0* I II Ill IV *

See Results

Volume

178

as a microcirin the

a synthetic site of immunoglobulin M and various opsonins (tuftsin,

pro-

In

perdin) (21). Postsplenectomy sepsis, although not as common as was once thought, still has a frequency of 4.25% and a mortality mate of 2.25%, and may occur up to 15 years after splenectomy (22). Despite recognition of this syndrome, splenectomy remained the mainstay of treatment for splenic injury until 1968, when the first documented series of successful nonsungical treatment in pediatnic patients with splenic trauma

was

reported

(3).

Even in the first successful nonsurgical treatment, the

recognized

that

not

study authors

all trauma

of

pa-

tients were candidates for this type of treatment, and that general guidelines for selecting patients in whom conservative treatment was likely to

needed

to be estab-

lished. Criteria for nonsurgical treatment in pediatric patients are genenally accepted to be hemodynamic stability after minimal fluid nesuscitation, documentation of injury with radiographic techniques, and absence

associated

severe

abdominal

injury (16,23,24). Strict adherence to these criteria alone has resulted in success rates of 95%-100% in pediatnc patients. These guidelines have also been used in adult patients with

Outcome Early

CT Class

to function

to be

of other

hemisplenectomy (all early

1).

shown

is-

culation filter and to be critical body’s defense against blood-borne bacteria, particularly encapsulated organisms such as Streptococcus. addition, the spleen is thought

be successful

in 54 Patients

Procedure

Splenic preservation after trauma become a frequently discussed in recent years. The spleen has

been

In addition,

without significant intrapenitoneal fluid on other abdominal injury are appropriate candidates for nonsurgical treatment, and that patients with

class

has sue

total scones early celio-

risk of in their

with

DISCUSSION

delayed rupture had scores for all four param-

as the value above which the delayed rupture is increased;

tients

and outcome was done by use of a Gtest with the Williams connection. In our patients, CT evaluation with this grading system and clinical outcome were found to be independent (P> .5).

outlined

with their proposed scoring system. The results of this CT grading system with our population of 29 adult patients are shown in Table 6. It is intenesting to note that patients who

panon-

In addition, inpatients (25%)

test of independence evaluation and clinical comparison was based mendation by Buntain

CT

with

by Resciniti et al (16) authors studied only

subsequently had were underscored

by use of this system. juries in another four

abdominal

evaluated

No Injury

0 1 0 0 0

Celiotomy

Splenic Salvage

0 1 5 2 0

Late

Splenectomy

0 1 0 2 0

No Injury

0 1 0 0 0

Celiotomy

Splenectomy

1 0 2 0 0

for explanation.

Number

#{149}

2

Radiology

483

#{149}

trauma, though

and the reportedly

success rates, alas high as 83%

(23,25),

are

lower

still

than

those

seen in pediatric patients. Several explanations have been proposed (although none has been confirmed) for the apparent differences in the outcome of the injured spleen in adults and children. Greatem elasticity in the nibs of pediatric patients with trauma than in the ribs of adult patients may result in a decreased likelihood of fracture or severe injury to the spleen (27,28). Another theory is that pediatric patients have a relatively larger splenic capsule-parenchyma ratio than do adults and may therefore be more mesistant to injury (28). Decreased contraction and retraction of injured splenic vessels with aging might also account for some differences in the ability of the spleen to heal (9). Despite the recent enthusiasm for splenic salvage in adult patients with trauma, several authors warn that in many cases splenectomy is still the procedure of choice, and that mdividual assessment of cases is necommended when one decides between splenectomy and splenic preservation (29-32). Reports describing the unpredictable natural history of the injured spleen, the lack of clean conrelation between the extent of injury and the clinical function of the spleen or the need for lapanotomy, and the possibility of missed hollow viscus injuries suggest that nonsungical treatment can have costly consequences even among the most camefully selected patients (13,14,31,3337).

Despite

reports

of success

Radiology

#{149}

ment and that patients with severe class II, all class III, and all class IV injuries undergo early lapanotomy.

tion

tam

that

early

surgical

intervention

more often results in successful splenic salvage than does celiotomy after delayed rupture has also encouraged both surgeons and nadiologists to devise systems for assessing the extent of injury and predicting the likely clinical outcome in these patients. Buntain et al (15) applied the grading system they devised to 46 patients with splenic injury and concluded that CT was correctly indicative of the existence of splenic injury in 28 of the 30 patients who underwent surgery. However, they did not show that CT was as successful in enabling prediction of the actual nature and extent of the injury in these

cases.

Interestingly,

CT

Other

authors system

have

obtained

tients injuries

might have been They recommended

with

class

undergo

I and

able that

some

nonsurgical

applied own

different

derwent

nonsungical

the patients

results.

more et a! (49) evaluated nal CT scans of 18 patients

the

Bunand

El-

abdomiwho un-

treatment

and

found that 33.5% of their patients had class III or IV injury and 61% had class II injuries. In fact, only one patient in the nonoperative series had a

un-

derscored the extent of the injury in six of their patients (20%). Buntain et al also stated that CT was correctly indicative of splenic injury in 16 nonsungical patients; however, because these patients never underwent surgical exploration, it is difficult to understand how the authons this.

have to their

to prove pa-

class treat-

II

Successful

Unsuccessful Nonsurgical Treatment (Delayed Celiotomy(

Nonsurgical Treatment

Figure

1.

CT scores

versus

results

of non-

surgical treatment according to the method of Resciniti et al. Dashed line maximum nonoperative scone.

with

conservative treatment in adults, early laparotomy is still recommended by many authors in the treatment of splenic trauma (35-39). Although many centers still advocate the use of diagnostic pemitoneal lavage (DPL) over CT in the diagnosis of blunt abdominal trauma (4043), the high specificity of CT over DPL, as well as the ability of CT to enable evaluation of the netnopenitoneum, has been well documented (44,45). The mole of CT specifically in the diagnosis of acute splenic injury has also been well established (1518,46-48). In addition to demonstrating the presence or absence of splenic injury, CT can also characterize type, depth, and location of the injury, as well as quantify the extent of intnapenitoneal hemorrhage (48). The specificity of abdominal CT in the evaluation of trauma, combined with the recognition of nonsurgical treatment as a therapeutic option in acute 484

splenic injury, has led many clinicians to attempt to correlate CT findings with a successful outcome in these patients (15-18,49). The realiza-

a.

b.

Figure 2. Images of a 19-year-old woman who underwent a delayed celiotomy and splenectomy. (a) Initial scan of the abdomen was normal. (b) A follow-up scan, obtained 28 hours later because of syncope, demonstrated numerous splenic fracture planes (straight arrow). A liver laceration (curved arrow) is also observed.

February

1991

be

class I injury. Of these patients, nonsurgical treatment failed in one patient only, a patient with a class III injury. Mirvis et al (18) devised a grading system similar to that of Buntain but with the addition of specific measurements for the depth of laceration and the size of existing hematoma. They concluded that the estimation of splenic injury with their grading system was not reliable in enabling prediction of the success on failure of nonsungical treatment.

We applied

the

Buntain

system

od to our areas

treatment in eight

of the

underwent

16 patients

who

surgical

procedures,

patients,

Buntain

increases system pretation readers.

meth-

we noted

several

in choosing

the

for each case. For small panenchymal

examinju-

II injury. (as

did

We also Mirvis

found

it difficult

et al [18])

be the

ranging

result

of a parenchymal

with an intact capsule, sular disruption would penisplenic (extracapsulam)

from splenic salvage to splenectomy (Table 5). In the two patients in our series who had class IV injuries, both completely shattered spleens were successfully observed, as were injunies in six of the 10 patients with class III injuries (Fig 3). Statistical analysis showed CT evaluation by this system and clinical outcome to

ma, a distinction

that

of these

patients

surgical

treatment,

volvement

3.

Images

of a 9-year-old

tamed at admission improved.

Volume

178

show

Number

#{149}

deep

2

boy who fractures

injury

and that a capresult in a hemato-

is cumbersome

dicated

to make with CT to begin with. Therefore, it is difficult to classify an injury as a subcapsulam hematoma without pamenchymal injury. The use of “significant” in this classification without a definition of the word also

did

well even

of splenic

with with

vessels

nonin-

(Fig

4).

safe

nonsurgical

treatment

in

their study, whereas a scone of 2.5 or greaten suggested an increased likelihood of delayed rupture. Our results with the system of Resciniti et al are shown in Table 6. We found that the three patients who

c.

underwent

dividing

of these cases, so this classification argued that these a Buntain class of to note that all four

Resciniti et al (16) describe a grading system for splenic injury in adults that is based on an interval scale of 0 to 6 points (Table 2). This system affords some advantage oven that of Buntain et al in that it allows for injuries isolated to the panenchyma without involvement of the capsule. In addition, a provision for questionable observations is supplied. A total scone of less than 2.5 in-

b.

Figure

there was no panenchymal involvement of the

spleen itself in any in the strict use of system it could be cases should have 0. It is interesting

dence, and this was due to the fact that the involved vessels were calcified on CT scans. In addition, the class I criteria call for “localized capsulam disruption or subcapsular hematoma, without significant panenchymal injury.” One would assume that a subcapsulan hematoma would

(Fig (50%)

chance that use of this result in subjective interand inconsistency among Another area of difficulty in

However, or capsular

to differenti-

ate between a penihilam versus nonpenihilar location of injury; this determination, as well as the question of involvement of major blood yessels, is subjective and not meproducible among interpreters. In only one case could we determine the involvement of blood vessels with confi-

to

the

will

classification has to do with the infancted spleens seen in four of our patients. The clear involvement of vessels in these cases would lead to a diagnosis of class III or IV injury.

ry without any capsular disruption would be classified as high as a class

surgery were classified incorrectly by use of this system. Injuries in four patients were underscored and injuries in four were ovensconed. Several patients with the same class and similar patterns of injury at CT required dif-

fenent

the

of weakness

correct class ple, a single

our patients at Rhode Island Hospital (Table 4) and found that in all three patients who had delayed rupture of the spleen, initial CT scans indicated successful nonsungical 2). In addition, injuries

independent. While applying

conservative the

spleen.

treatment

Subcapsular

but who fluid

is present.

initially

had

(c) Four

a class weeks

III CT score. later

the

(a, b) CT scans

traumatic

injuries

Radiology

obhave

#{149} 485

eventually

had

had lower parameters, total score,

rupture

of the

spleen

mean scores for all four as well as a lower mean than those in whom early

celiotomy was recommended. these patients had total scores than

2.5

(Fig

1). In addition,

found that those qumned splenectomy tomy

had

Two of of less

scores

than

Statistical

that

analysis

CT scores

clinical

in this

outcome

were

independent.

with

The location and shape of and the nature of its capmakes this differentiation

CT difficult

5). It is, however, tinction to make,

has

been

violated.

en report

the

by Scatamacchia system of Resciniti

of this same Scatamacchia distinction not

were

then

able

lam scone

subcapsulam

an accurate

to their

cases,

of the

capsule

exclusively

study.

on

because

et al

capsuthe

is determined the

basis

of the

location of the associated fluid. In that study, assigning a capsular score of one point in cases of subcapsulan fluid

might

have

resulted

in

higher

splenic injury scores when, in fact, the capsule was still intact. Elmone et al (49) also used the scoring system of Resciniti et al in their study and found that 12 of 18 patients had scones of 2.5 or greater. Only one of these 12 patients required delayed surgery; therefore, they concluded that these CT findings alone should not

be

used

to determine

the

need

Radiology

#{149}

due

largely

the CT abdominal

this

to the

readers studies

the

in

grading

explanation

itself

cleanly

of any

are

system

vital

used

to the

in the

of treatment

integrity

detemmina-

of patients.

Perhaps

definition of the various pawould help decrease the

subjectivity

of these

Another

systems.

general

the interpretation required by these

can

depend

If these

weakness

is that

of subtle classification

findings sys-

on scanning systems

are

techto be used

at all, a universal scanning protocol for CT scans of the traumatized abdomen needs ly outlined

to be devised and for other potential

In summary, that

the

it is our

posttnaumatic

carefulusers. of the

with studies

natural

spleen

of the

injured

and have demonstrated the lack correlation between the anatomic tent of the injury and the clinical come in many cases (13,14,31,3335,37,50).

with

Our

findings

data

are

in other

treatment in patients

is a viable with splenic

alin-

jury, and we acknowledge that CT has cleanly been shown to be a valuable diagnostic tool in the evaluation of these patients. However, the construction of CT grading systems to evaluate the extent of injury in an effort to predict clinical outcome is not practical in our experience. Regardless of which parameters are used in the grading systems, a small but significant number of patients with low scores or even abdominal CT scans that appear normal experience delayed rupture of the spleen. In most cases, CT is accurate in enabling detection of, and often in quantifying, injury to the spleen, but the extent of injury does not necessarily enable prediction of need for surgical intervention. In all patients with splenic injury, the ultimate decision for laparotomy should be based on clinical status and not on radiographic findings. CT is indeed a useful tool in mitial documentation of injury and in following the progression of the injuned spleen as it heals, but we believe that clinical suspicion and expemience should remain the primary detemmining factors in the selection of both adult and pediatric patients for nonsungical treatment of splenic injury. U

contention outcome

injured spleen is not predictable use of these methods. Several have warned of the unpredictable history

nonsurgical temnative

References King H, Schumacker HB. I: susceptibility to infection tomy performed in infancy.

2.

Malangoni MA, Dillon LD, Klamer TW, Condon RE. Factors influencing the risk of early and late serious infection after splenectomy or trauma. Surgery 1984;

3.

Upadhyaya P, Simpson JS. ma in children. Surg Gynecol

1952;

of a exout-

Splenic after Ann

studies splenecSurg

136:239-242.

96:775-783.

in agreement

studies

1.

that

Splenic Obstet

trau1968;

126:781-790.

for

early lapanotomy in the patient with the more severely injured spleen. Segmental splenic infarction proved to be another problem with the grading system of Resciniti et al. Of the four patients with infarcted spleens in our study, two had scores of 2.0, one had a scone of 1.5, and one a score of 0 (Fig 4). The points that were given in each case were for the presence of fluid in the abdomen or pelvis and not for any injury to the 486

sults

It is

Scatamacchia

them-

applying

but

nique.

and

of as

points out an inherent weakness in these systems. Consistent, objective interpretation and reproducible me-

tems

problem, to make no

in their

how

to assign

integrity almost

a lat-

institution

et al (17) used the et al, but because

fluid

clean

accurately

tion

between

were among the

systems,

a clearer rameters

differentiation et al chose

penisplenic

and

dis-

same

seen

interpretation parameters,

CT findings

studies

(Fig

Interestingly,

from

as in the

an important especially

when

paren-

were

selves, led to inconsistency and imreproducibility of the data. It is indeed possible that the discrepancies between our results and those of the

on impossible

one uses this particular grading system, which enables distinction between an intact capsule and one that

no clear

in the system

variability interpreting

and

A major difficulty that we encountened with the system of Resciniti et al was the need to differentiate between penisplenic fluid and subcapsulan fluid. the spleen sule often

because

Other general problems were encountered with the grading systems of Buntain et al and Resciniti et al.

cited

showed

system

on capsular defects of these patients.

well

those

who were candidates for splenic salvage procedures (splenonrhaphy, splenic artery ligation, hemisplenectomy).

itself,

chymal in any

Subjectivity the grading

we

patients who meat early celio-

lower

spleen

4.

Figures

5. 4, 5.

(4) Infarcted

spleen

without

evidence

of panenchymal

injury.

Because

of vas-

culan involvement, this injury is classified Buntain III. The patient underwent conservative treatment and did well. (5) Abdominal CT scan of a 22-year-old patient after a motor vehicle injury. An obvious splenic parenchymal injury (curved arrow) was noted, but the fluid (straight arrow) is difficult to categorize as penispienic, subcapsular, or both.

February

1991

4.

5.

6.

7.

King DR, Lobe TE, Haase GM, Boles ET. Selective management of injured spleen. Surgery 1981; 90:677-680. Em SH, Shandling B, Simpson JS, Stevens CA. Nonoperative management of the traumatized spleen in children: how and why. J Pediatr Surg 1978; 13:117-119. Douglas GJ, Simpson JS. The conservative management of splenic trauma. J Pediatr Surg 1971; 6:565-570. Rescorla FJ, Grosfeld JL. Splenic and liven trauma in children. Indiana Med 1989;

20.

21. 22.

23.

82:516-520.

8.

9.

10.

1 1.

12.

13.

14.

15.

16.

17.

18.

19.

Tom WW, Howells GA, Bree RL, Schwab R, Lucas RJ. A nonoperative approach to the adult ruptured spleen sustained from blunt trauma. Am Sung 1985; 51:367-371. Morgenstern L, Uyeda RY. Nonoperative management of injuries of the spleen in adults. Sung Gynecol Obstet 1983; 157:513-518. Johnson H, Shatney CH. Splenic injuries in adults: selective nonoperative management. South Med J 1986; 79:5-8. Wiebke EA, Sam MG, Fishman EK, Ratych RE. Nonoperative management of splenic injuries in adults: an alternative in selected patients. Am Sung 1987; 53:547-552. Moss JF, Hopkins WM. Nonoperative management of blunt splenic trauma in the adult: a community hospital’s experience. J Trauma 1987; 27:315-318. Nallathambi MN, Ivatury RR, Wapnir I, Rohman M, Stahl WM. Nonoperative management versus early operation for blunt splenic trauma in adults. Sung Gynecol Obstet 1988; 166:252-258. Malangoni MA, Levine AW, Droege EA, Aprahamian C, Condon RE. Management of injury to the spleen in adults: resuits of early operation and observation. Ann Sung 1984; 200:702-705. Buntain WL, Gould HR. Maull K!. Predictability of splenic salvage by computed tomography. J Trauma 1988; 28:24-31. Resciniti A, Fink MP, Raptopoulos V. Davidoff A, Silva WE. Nonoperative treatment of adult splenic trauma: development of a computed tomographic scoring system that detects appropriate candidates for expectant management. J Trauma 1988; 128:828-831. Scatamacchia SA, Raptopoulos V. Fink MP, Silva WE. Splenic trauma in adults: impact of CT grading on management. Radiology 1989; 171:725-729. Minvis SE, Whitley NO, Gens DR. Blunt splenic trauma in adults: CT-based classification and correlation with prognosis and treatment. Radiology 1989; 171:33-39. Sokal RR, Rohlf FJ. Biometry: the principies and practice of statistics in biological research. 2nd ed. New York: Freeman, 1981.

Volume

178

Number

#{149}

2

24.

25.

26.

27.

Williams DA. Improved likelihood ratio tests for complete contingency tables. Biometrika 1976; 63:33-37. Pearson HA. Splenectomy: its risks and role. Hosp Pract 1980; 15:85-94. Balfanz JR. Nesbit ME, Jarvis C, et al. Overwhelming sepsis following splenectomy for trauma. J Pediatr 1976; 88:458460. Cogbill TH, Moore EE, Junkovich GJ, Mornis JA, Mucha P. Shackford SR. Nonoperative management of blunt splenic trauma: a multicenter experience. J Trauma 1989; 29:1312-1317. Pearl RH, Wesson DE, Spence U, et al. Splenic injury: a five-yean update with improved results and changing criteria for conservative management. J Pediatn Sung 1989; 24:428-431. Longo WE, Baker CC, McMillen MA, Modlin IM, Degutis LC, Zucker KA. Nonopenative management of adult blunt splenic trauma: criteria for a successful outcome. Ann Sung 1989; 210:626-629. Zucker K, Browns K, Rossman D, Hemingway D, Saik R. Nonoperative management of splenic trauma: conservative or radical treatment? Arch Sung 1984;

36.

Fischer RP, Miller-Crotchett P. Reed RL. Gastrointestinal disruption: the hazard of nonoperative management in adults with blunt abdominal injury. J Trauma 1988; 28:1445-1449.

37.

Taylor

119:400-403.

42.

Mazel

M.

Traumatic

rupture

38.

39.

in acute

40.

41.

of spleen

with special reference to its characteristics in young children. J Pediatr 1945; 26:8228.

29.

30.

31.

32.

33.

88. Delius

RE,

Frankel

W,

Conan

AG.

A com-

panison between operative and nonoperative management of blunt injuries to the liver and spleen in adult and pediatric patients. Surgery 1989; 106:788-793. Mucha P, Daly RC, Fannell MB. Selective management of blunt splenic trauma. Trauma 1986; 26:970-978. Mucha P. Changing attitudes toward the management of blunt splenic trauma in adults. Mayo Clin Proc 1986; 61:472-477. Pickhandt B, Moore EE, Moore FA, McCroskey BL, Moore GE. Operative splenic salvage in adults: a decade perspective. J Trauma 1989; 29:1386-1391. Tibi P, Ouriel K, Schwartz SI. Splenic injury in the adult: splenectomy, splenonrhaphy, or nonopenative management. Contemp Sung 1985; 26:73-76. Brick

SH,

Taylor

GA,

Potter

BM,

Eichel-

43.

44.

45.

46.

47.

35.

Mahon

PA,

management blunt trauma: 149:716-721.

Sutton

JE.

Nonoperative

of adult splenic a warning. Am

injury J Sung

due to 1985;

ME,

Potter

BM,

Eichel-

abdominal

injuries.

Sung

Clin

R. The clinical

impact

of CT for

blunt abdominal trauma. AJR 1985; 145:1191-1194. Fedenle MP, Gniffiths B, Minagi H, Jeffrey RB. Splenic trauma: evaluation with CT. Radiology 1987; 162:69-71. Mall JC, Kaiser JA. CT diagnosis of splenic laceration.

48.

Fallat

North Am 1988; 68:255-268. Fabian TC, Mangiante EC, White TJ, Patterson CR, Boldreghini 5, Bnitt LG. A prospective study of 91 patients undergoing both computed tomography and pentoneal lavage following blunt abdominal trauma. J Trauma 1986; 26:602-607. Frame SB, Browden 1W, Lang EK, McSwain NE. Computed tomography versus diagnostic peritoneal lavage: usefuiness in immediate diagnosis of blunt abdominal trauma. Ann Emeng Med 1989; 18:513-516. Meyer DM, Thai ER, Weigelt JA, Redman HC. Evaluation of computed tomography and diagnostic penitoneal lavage in blunt abdominal trauma. J Trauma 1989; 29:1168-1170. Sorkey AJ, Farnell MB, Williams HJ, Mucha P. Ilstnup DM. The complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma. Surgery 1989; 106:794-801. Fedenle MP, Goldberg HI, Kaiser JA, Moss AA, Jeffrey RB, Mall JC. Evaluation of abdominal trauma by computed tomography. Radiology 1981; 138:637-644. Wing VW, Federle MP, Morris JA, Jeffrey

RB, Bluth

bergen

34.

MR. Hepatic and splenic injury in children: role of CT in the decision for laparotomy. Radiology 1987; 165:643-646. Buckman RF, Dunham CM, Kerr TM, Miiitello PR. Hypotension and bleeding with various anatomic patterns of blunt splenic injury in adults. Sung Gynecol Obstet 1989; 169:206-212.

GA,

bergen MR. The role of computed tomography in blunt abdominal trauma in children. J Trauma 1988; 28:1660-1664. Pitcher ME, Cade RJ, Mackay JR. Splenectomy for trauma: morbidity, mortality, and associated abdominal injuries. Aust N z J Sung 1989; 59:461-463. Meredith JW, Trunkey DD. CT scanning

AJR

1980;

134:265-269.

Jeffrey RB, Laing FC, Fedenle MP, Goodman PC. Computed tomography of splenic trauma. Radiology 1981; 141:729732.

49.

50.

Elmone JR. Clark DE, Isler RJ, Homer WR. Selective nonoperative management of blunt splenic trauma in adults. Arch Surg 1989; 124:581-585. Jeffrey RB. CT diagnosis of blunt hepatic and splenic injuries: a look into the futune. Radiology 1989; 171:17-18.

Radiology

#{149} 487