Restriction of Activity After Splenic Injury
Restriction of Activity After Splenic Injury
ABSTRACT & COMMENTARY
Synopsis: Following confirmation of splenic injury by CT scan after blunt trauma, serial ultrasounds (US) permit documentation of healing. Patients can return to full activity when the US documents healing.
Source: Lynch JM, et al. Computed tomography grade of splenic injury is predictive of the time required for radiographic healing. J Pediatr Surg 1997;32:1093-1096.
Non-operative management of blunt splenic trauma in children has been widely accepted as safe and effective. However, it has not been well established when such children should be allowed to resume full, unrestricted activity. Lynch and associates at the Regional Pediatric Trauma Center at the Children’s Hospital of Pittsburgh followed 58 children with splenic injury following blunt abdominal trauma. Mechanism of injury included motor vehicle crashes (11), pedestrian struck by motor vehicle (5), falls (13), bike crashes (12), horses (5), sports-related (8), and all-terrain vehicles (5).
Their protocol included an initial abdominal CT scan to grade the degree of splenic injury from localized capsular disruption of hematoma without parenchymal injury (grade I) to a completely shattered or fragmented spleen (grade IV) according to the classification of Buntain.1
A baseline ultrasound (US) was performed that correlated with the CT scan in all study cases. Follow-up US were performed at four- to six-week intervals in patients with grade II-IV injury until complete homogenicity of the splenic tissue was observed. Mean time to healing ranged from 3.1 weeks in grade I to 20.7 weeks in grade IV injury. Lynch et al conclude that pediatric patients who have suffered splenic injury can safely return to full activity when the US documents healing.
COMMENT BY JOHN SEASHORE, MD
The management of splenic injury in children has changed radically over the last 25 years. Prior to that time, the standard of care was to remove the spleen for even the slightest injury because of the reported risk of delayed or secondary hemorrhage and the belief that the spleen had no essential functions that could not be assumed by other organs. Two major developments served to challenge, then change, this dogma. First, the syndrome of overwhelming post-splenectomy sepsis was identified. Second, radionuclide scans of the liver and spleen made it possible to diagnose many more splenic injuries than could be identified from clinical examination alone. Thus, the incidence of ruptured spleen and, therefore, the number of splenectomies, was increasing in the late 1960s. A few surgeons recognized early on that many children with splenic injury were in fact hemodynamically stable and might not need an operation, but they were generally ignored, if not relieved. It was primarily the group of surgeons at the Hospital for Sick Children in Toronto that finally convinced the pediatric surgical community that it was possible to salvage at least some injured spleens.2 Non-operative, expectant management of splenic injury in children has gradually become the standard of care, and today, only about 5% of children require splenectomyusually for spleens that are completely shattered.3
A number of questions remain unanswered, including the need for ICU observation, days of bed rest, days in hospital, and time to resumption of activities. The paper by Lynch et al attempts to answer the last of these but, unfortunately, falls short. In the second paragraph of the paper, Lynch et al make the assumption that "US resolution of the splenic injury is equivalent to true anatomic integrity of the spleen." This assumption has never been proven by any study, including the present one. All patients were followed until the US was normal, but the length of follow-up after that is not given; therefore, we are left to assume that there were no instances of late rupture of the spleen. In a discussion of this paper, which was published with it, Lynch et al state that they actually tried to keep their patients out of contact activities for "a few months" after US resolution. For all of these reasons, their conclusion that patients can return to full activities once the US is normal is not supported by their data.
Before the availability of good diagnostic studies, there was a substantial incidence of delayed rupture of the spleen. This occurred in individuals who sustained an injury but were clinically stable and, therefore, sent home.3 Days to weeks later, they presented with evidence of splenic injury, either from continued or renewed bleeding. The peak incidence of delayed rupture was at 48 hours post-injury. The number of cases then declined in an asymptotic curve that approached zero at about three months, although there were occasional cases reported even longer after injury.4 These old data are the basis for the three-month restriction of activities that many surgeons prescribe.
The present paper should made us rethink this position. Lynch et al have documented a strong correlation between the grade of injury and the time needed for sonographic healing (which is, in fact, the essence of the title). It also suggests useful guidelines for the frequence of imaging studies based on the grade of injury. If it can be proven that restoration of normal architecture by imaging studies does equate to structural integrity of the spleen, then a new standard for care could be established. A multicenter study of a large number of children who are managed according to the protocol suggested in the paper and followed for a minimum of 6-12 months could nicely answer this question. (Dr. Seashore is Professor of Pediatrics and Surgery, Yale University School of Medicine.)
References
1. Buntain WL, et al. Predictability of splenic salvage by computed tomography. J Trauma 1988;28:24-31.
2. Douglas GJ, Simpson JS. The conservative management of splenic trauma. J Pediatric Surg 1971;6: 565-569.
3. Ein JH, et al. Non-operative management of traumatized spleens in children: How and why. J Pediatric Surg 1978;13:117.
4. Sizer JS, et al. Delayed rupture of the spleen. Arch Surg 1966;92:362-366.
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