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Management of blunt splenic injury: down the rabbit hole and into the bucket
  1. Stephanie A Savage
  1. Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
  1. Correspondence to Dr Stephanie A Savage; sasavage2{at}


Management of splenic trauma has changed dramatically over the past 30 years. Many of these advances were driven by the Memphis team under the leadership of Dr. Timothy Fabian. This review article summarizes some of those changes in clinical care, especially related to nonoperative management and angioembolization.

  • spleen
  • abdominal injuries

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Matching into a fellowship in Memphis, TN, had a lot of implications beyond learning to be a trauma surgeon at one of the busiest trauma centers in the country. Crossing the threshold of the Elvis Presley Trauma Center was joining a family or the Memphis Mafia depending on your preference. But as with all families, there were idiosyncrasies, rules and expectations. And one of the behaviors modeled time and again was that of scientific curiosity. Memphis did not have a lot of fancy labs and expensive toys but they did have a history of research productivity. Dr Fabian, the head of the family to perpetuate the analogy, was legendary for asking a question and then following it down the rabbit hole. All of us who have worked for Dr Fabian remember a time he would simply show up in our office, sit down across the desk from us and say “What the heck are you doing?” This was prime time to bounce a concept off him or get direction for your research trajectory.

This intellectual curiosity, along with the wealth of clinical material available at Memphis, represented a wonderful opportunity to pursue a rigorous and longitudinal approach to answer some of the most controversial issues of the day. An excellent example of this is the issue of the management of blunt splenic injury (BSI). Though we all know that the spleen loves the bucket, Dr Fabian and his team at Memphis set out to prove if and how much love there was. During the course of 13 papers which he coauthored and 21 subsequent papers from past fellows and faculty, the Memphis group evaluated and re-evaluated the management of BSI during a 30-year period (figure 1).

Figure 1

Network analysis of the impact of Dr Timothy Fabian's blunt spleen injury research.

Returning to this body of literature today, it is fascinating to observe what was gospel gradually morph into the practice patterns we now use. The first BSI paper in Dr Fabian’s library was published in the Journal of the Tennessee Medical Association in 1993.1 This historic document, preserved in an actual book (, saw an early foray into the nonoperative management of an injured spleen. The initial decision to observe was clearly radical and somewhat aggressive, as the authors noted at the time that only 12% to 15% of adults were candidates for nonoperative management. The threshold for failure was also different, and lower, as the patient was taken for splenectomy on hospital day #4 after his heart rate rose 10 beats per minute (from 95 to 105 bpm) and his hematocrit dropped from 39% to 31%. The authors’ conclusions were prescient however. “The data presented here support the nonoperative management of BSI in selected adult and pediatric patients. Selection criteria must be strict and the threshold for subsequent operative intervention must be low.”1

During the following 5 years, Fabian et al worked to define the strict selection criteria needed for the nonoperative approach to BSI. Increased utilization and sophistication of CT allowed identification of contrast blushes and abnormalities of the splenic vasculature, such as pseudoaneurysms. These findings served as clinical predictors of increased failure rates.2–4 Bee et al further defined clinical factors which were associated with increased nonoperative failure including low Glasgow Coma Score, hypotension, large hemoperitoneum and older age.5 Importantly, during this same period, the use of angioembolization to manage some of these concerning characteristics allowed trauma surgeons to attempt splenic salvage in even more patients.

True to Fabian’s leadership and approach, it was down the rabbit hole to try and understand every aspect of BSI and management options (table 1). Santaniello et al, Miller et al and Malhotra et al looked at how BSI was managed in the setting of other major injuries.6–8 Weinberg et al evaluated serial imaging to understand the incidence and management of pseudoaneurysm in BSI.9 Savage et al and Zarzaur et al followed BSI longitudinally to determine the time to healing and the incidence of late rupture.10 11 These inquiries led to multicenter studies sponsored12 by the American Association for the Surgery of Trauma, Western Trauma Association and others to further refine our management strategies.13–34

Table 1

Longitudinal study of blunt spleen injury by Fabian et al

The management of BSI remains surprisingly controversial to this day. Though most would agree that nonoperative management is the gold standard in hemodynamically stable patients, that is about all that we agree on. Centers vary significantly in timing and frequency of angioembolization and the threshold for splenectomy versus continued observation in the face of physiologic changes. Despite such variations, Fabian’s contribution has been fundamental. To return to the conclusion from his 1993 paper, “Selection criteria must be strict and the threshold for subsequent intervention must be low.”1

At the core, Dr Fabian’s contribution to splenic science has been to define the natural history of the bluntly injured spleen when left in situ. The fundamental aspect of this was identification of the incidence of pseudoaneurysm and the description of how this vascular abnormality contributes to delayed failure. Much of his subsequent oeuvre then expanded on this core concept including patient, global injury characteristics and the evolution of the spleen in the wild, that is, time to healing or rupture after discharge. With his quintessential ‘he he he,’ bow tie and soft-spoken presence, Dr Fabian has influenced a generation of us to truly learn about the spleen and remains a much-loved mentor.

It is a relative triumph that nonoperative management has such a high success rate. In part, this is due to a refinement of our management strategies during the last three decades but is also in large part due to improved patient selection (a selection bias perhaps). Fabian’s “strict criteria” are the heart of successful management of BSI because, fundamentally, the spleen does love the bucket. Our job as trauma surgeons is to ensure the right ones get there.

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  • Contributors I am the sole author of this work, though David Livingston provided editorial input.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.