Trauma is a leading cause of mortality and disability, universally accounting for 4.4 million deaths annually, according to the World Health Organization.^[1] One of the most commonly injured organs in blunt abdominal trauma is the spleen.^[2] Patients with splenic injuries may present with different clinical presentations depending on the severity of the injury. In hemodynamically unstable patients, Focused Assessment with Sonography for Trauma (FAST) is performed, and a positive FAST defines the need for immediate laparotomy. In hemodynamically stable patients, the gold standard for diagnosing splenic injuries is the abdominal CT scan. The World Society of Emergency Surgery (WSES) classification system for splenic injuries by the American Association for the Surgery of Trauma (AAST) has been established. This classification divides splenic trauma into 5 categories depending on the CT findings.^[3]

The treatment options traditionally consist of operative and non-operative management (NOM). The latter is a prevailing course of treatment in hemodynamically stable patients and includes close monitoring, overall patient support, and a follow-up CT scan within 24-72 hours, as the risk of delayed subcapsular hematoma rupture or pseudoaneurysm rupture remains.^[2,3] Splenic artery embolization is an emerging course of treatment that offers the advantage of splenic salvage and may further establish non-surgical management.^[2] In hemodynamically unstable patients or patients with clinical signs of peritonitis, operative management is the course of treatment. In splenic injuries of grade 3 and above or in case of NOM failure, surgery should be considered.^[3]

Our study aims to describe the management and outcomes in our hospital over a ten-year period, 2014-2024. We assessed the grade of the injury, the treatment strategies, the length of hospitalization, transfusion requirements, morbidity, and mortality. In addition, we performed a systematic review of the existing literature to evaluate the management of spleen injuries in various Trauma Centers and assess the outcomes of the different treatment strategies.

A retrospective analysis of registry data was conducted for patients with traumatic splenic injury admitted to the General Hospital of Nikaia, Greece, from 2014 to 2024. Patients were identified from the institutional trauma registry. Patients undergoing splenectomy for non-traumatic reasons were excluded. Demographic data, mechanism of injury, radiology reports, operative details, antiplatelet drug treatment, mortality outcomes, and transfusion requirements were extracted by two independent reviewers (AE and VP) from hospital electronic records. The classification of splenic injury was made according to the American Association for the Surgery of Trauma (AAST) splenic injury scale.^[3]

Patients were divided into a NOM group and an operative group. Due to limited availability of an interventional radiologist, embolization of the splenic artery was not used as a treatment option for splenic rupture in our patient population. Primary outcomes were mortality, platelet count, and possible initiation of anti-platelet treatment, red blood cell (RBC) and fresh frozen plasma (FFP) transfusions, course of treatment, and the length of hospital stay. Mortality was defined as in-hospital death during the index admission. Transfusion requirements included units of red blood cells and fresh frozen plasma administered during hospitalization. Our study was approved by the Hospital’s Ethics Committee and all included patients provided a written consent for the use of their medical files.

Furthermore, a systematic review of the relevant publications was conducted in three databases, PubMed, Scopus, and the Cochrane Library, until July 22, 2025, and reported in accordance with the PRISMA 2020 guidelines. Keywords used were “traumatic,” “spleen,” “injury,” “splenectomy,” “blunt splenic trauma,” and “management.” Eligible studies for inclusion complied with the following inclusion criteria: More specifically, they should be published after 2000 so as to be closer to modern data and guidelines and describe the management of traumatic spleen injury. The studies should include a non-operative management and an operative management group of patients. Studies in which an angioembolization group was included were also accepted. Randomized controlled trials (RCTs), cross-sectional, cohort, interventional, observational follow-up, and longitudinal studies, as well as prospective and retrospective studies, were all eligible for inclusion. Case reports, letters to the editor, systematic reviews, case series, and books were excluded.

Two independent reviewers (AE and VP) screened the titles and abstracts based on the predefined inclusion and exclusion criteria. After the initial screening, a full-text assessment of the articles was performed. Disagreements were settled through discussion, but in the case of an inconclusive decision, a third reviewer (IK) resolved the conflict. The study selection process is shown in the PRISMA 2020 flow chart presented in Fig. 1.

Data extraction of the included articles was conducted in a data extraction sheet, which presented the following information: first author, publication year, study design, aim of the study, primary and secondary outcome, study population, age and sex, mechanism of injury, grade of injury, treatment, transfusion requirements, hospital stay, mortality and complications.

The risk of bias of the included studies was assessed with the ROBINS-I V2 tool for non-randomized studies. The following seven domains were evaluated: risk of bias due to confounding, risk of bias in classification of interventions, risk of bias in selection of participants into the study (or into the analysis), risk of bias due to deviations from intended interventions, risk of bias due to missing data, risk of bias arising from measurement of the outcome, and risk of bias in selection of the reported result. Possible risk of bias in judgments was low, moderate, serious, and critical. Two reviewers (AE, VP) independently rated all the included studies.

During the period of our study, 68 patients presented in the emergency department of our hospital with splenic injury, with the most common cause being road traffic accidents, and were all included in our study. 58 patients were males and 10 were females with a mean age of 42 years (range from 17 to 82 years). All patients underwent a CT scan on admission, and according to the AAST grading, 16 were grade I, 14 were grade II, 12 were grade III, 6 were grade IV, and 20 were grade V. Demographics, clinical characteristics, and complications are demonstrated in Table 1.

Our study describes the management of traumatic splenic injuries presented in our hospital over the last decade. NOM was applied to most of our patients, following the international guidelines. Operative management was chosen for the hemodynamically unstable patients with high-grade injuries. The option of splenic embolization was not available in our hospital. In addition, our study also captures the management of traumatic splenic injuries as presented in the literature. A significant shift towards NOM is noted, and splenic embolization seems an important tool to salvage the organ.

In our experience, most traumatic spleen injuries are a result of blunt trauma in motor vehicle accidents or falls. Lower-grade injuries are admitted to the surgical department for close monitoring, daily routine blood examination, and follow-up CT at 72 hours. Higher-grade injuries are usually treated operatively, especially in the case of an unstable patient when a positive FAST is performed in the emergency department and the patient is driven directly to the operating table for exploratory laparotomy and splenectomy. In the case of a stable patient, a CT scan is performed, and if active bleeding of the splenic artery or a ruptured spleen is found, the treatment of choice is surgery. In our opinion, this is the case when an angioembolization of the actively bleeding vessel would be an acceptable, even preferable, option to surgery, but unfortunately, an interventional radiologist is not always available in our hospital. Still, the proportion of NOM treatment in our hospital is similar to that of the literature (61.7% in our hospital vs. 60.5% in the literature), with only 2 patients in our study failing NOM treatment and requiring surgical intervention (95.2% success rate of NOM). Perhaps, if a permanent interventional radiologist were available, these two patients with grade III injuries could have been treated with embolization rather than operatively. This highlights that even non-trauma centers, where also the option of an interventional radiologist may not be available, may provide adequate management in splenic trauma patients with good outcomes, in accordance with the international guidelines and the results from the literature.^[20]

The literature search is consistent towards a NOM of splenic trauma, especially in low-grade splenic trauma. Bontrager et al. pointed out the low rate of surgical intervention in low-grade blunt splenic trauma^[21], and age does not appear to be a restrictive factor for NOM application^[22]. Ruhnke et al. further highlight the low failure rate of NOM management and outline active bleeding and hemoglobin decrease as the sole indicators for operative treatment.^[23] Conservative management has even been applied to penetrating trauma patients, although spleen-preserving surgery or splenectomy is more commonly opted for, presenting similar mortality rates.^[24] Splenic repair surgery has also been suggested for patients with blunt splenic trauma and has been associated with lower mortality rates.^[25] However, still spleen-preserving surgeries are fewer than splenectomies even in low-grade injuries.^[26]

Splenic embolization is widely used even for higher-grade splenic injuries with good results. Cinquantini et al. report an overall 91% success rate of non-surgical treatment that is the combination of NOM and embolization.‌^[27] The use of splenic embolization is a safe option even for higher-grade splenic injuries, with the advantage of splenic preservation.^[12,28] Bhullar et al. reported a higher tendency for NOM treatment and a simultaneous lower tendency for OM in their ten-year cohort study. When comparing the OM and NOM groups, the former presented higher ISS and mortality scores. When comparing the two NOM groups, patients undergoing AE had higher ISS scores and higher grades of splenic injury. In addition, they reported a decreased failure of NOM treatment in higher-grade splenic injuries (grade IV-V). In their study the indications for AE were contrast blush in the CT and decreasing hemoglobin, as these were the reasons for conservative management failure.^[29] Clements et al. propose angiography for possible vascular injuries in grade III patients who are at risk for re-bleed, as in their study 18 patients with occult vascular injuries were not detected at initial CT.^[28]

However, the literature is not entirely consistent on the results of angioembolization, as it has also been described as overused^[30], and it is not described with precision when surgery or angioembolization should be performed. After all, angioembolization is an interventional approach and may lead to complications such as rebleeds, splenic abscess, infarcts, and access site pseudoaneurysms, which may require further treatment and hospitalization such as endovascular stent placement, guided drainage, and even surgery.^[31,32] Duschene et al. have even described a fourfold higher Adult Respiratory Distress Syndrome (ARDS) incidence rate in patients post embolization than post splenectomy, though the mortality rates were similar.^[33] Still, angioembolization remains a minimally invasive technique with the additional benefit of preserving the organ.

Another interesting remark in our study is the positive correlation of the number of platelets and the grade of splenic injury. In our study, two grade I and II patients received antiplatelet therapy prior to their injury and one patient during hospitalization. In the operative management group, three patients initiated antiplatelet therapy post-splenectomy. An increase in the number of platelets was found in all splenic injuries but was statistically significant only in patients with grade V splenic injuries. Thrombocytosis after splenectomy has already been established in the literature, with many patients initiating antiplatelet drug therapy.^[34,35] Chia et al. found that the platelet count seems to gradually increase in a period of 16-17 days after the splenic injury, independently of the course of treatment. Thrombocytosis is more likely to occur in patients with total splenectomy than spleen-preserving management, and it has been found to be independent of the length of stay, grade of injury, ISS score, age, and need for blood transfusion.^[34] Pommerening et al. noted that traumatic splenectomy is a hypercoagulable state that initiates at 48 hours after injury and continues for at least 5 days.^[35] Kovar et al. noticed an increasing tendency in the platelet count in all patients with splenic injuries, but this differs depending on the intervention type regardless of the possible infection.‌^[36] Platelet count should thus be closely monitored, and antiplatelet drug therapy should be initiated when needed. The possibility of protective initiation of antiplatelet drug therapy depending on the grade of injury should also be examined in future studies.

The present study is subject to several limitations. In our hospital, an interventional radiologist is not always available for splenic embolization, and thus, many patients with higher-grade injuries or with active bleeding undergo operation instead of NOM. Secondly, our sample size is small, thus limiting generalization of the results. However, according to our research, this is the first study describing the management of blunt splenic injuries in our country and is able to provide valuable insight into the outcomes of non-operative management in a real-world clinical setting. Thirdly, the risk of bias assessment of the included studies in our systematic review shows moderate bias in eight studies, which may affect the conclusions. In our opinion, though, in non-randomized retrospective studies, a certain degree of confounding is to be expected. Our study presents a few strengths. To our knowledge, this is the first systematic review of the management of blunt splenic trauma and may be used to illustrate the application of the existing guidelines of blunt splenic trauma in trauma centers internationally. Moreover, it highlights the lack of specific guidelines for splenic embolization, which may present as an effective alternative.

A shift towards NOM worldwide is noticed. Surgical intervention is restricted solely for hemodynamically unstable patients. Splenic embolization is an effective alternative and may be used to further establish non-surgical management while it also offers the benefit of splenic salvage. However, more specific guidelines regarding the selection of patients undergoing embolization are needed. Close monitoring of the platelet count and initiation of antiplatelet drug therapy are recommended.