Operative Versus Nonoperative Management in High-Grade Blunt Splenic Injuries: A 10-year Analysis

High-grade blunt splenic injury (American Association for the Surgery of Trauma [AAST] Grades IV and V) carries substantial hemorrhage risk, yet long-term real-world outcomes following sustained implementation of a protocolized, physiology-first management algorithm remain limited. This study evaluates a decade of outcomes comparing operative management (OM) and nonoperative management (NOM) of AAST Grade IV-V blunt splenic injury at a mature Level I trauma center.

Adults with AAST grade IV and V blunt splenic injury treated at a level I trauma center (2015 to 2024) were reviewed. Management prioritized OM for persistent hypotension despite early blood-product resuscitation and NOM with intensive care unit observation and splenic artery embolization for stable patients. The primary outcome was in-hospital mortality. Secondary outcomes included NOM failure (reintervention for hemorrhage control) and a composite of mortality and/or reintervention. Multivariable regression adjusted for injury severity, hypotension, and tachycardia.

Of 386 patients, 196 (50.8%) underwent upfront OM and 190 (49.2%) NOM. One hundred thirty (68.4%) NOM patients underwent splenic artery embolization. NOM failure occurred in 13/190 (6.8%). After adjustment, NOM was not associated with mortality (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.44-2.44, P = 0.94) or the composite outcome (OR 1.02, 95% CI 0.54-1.91, P = 0.96). Mortality was associated with injury severity score (OR 1.06, 95% CI 1.03-1.10, P < 0.001) and hypotension (OR 2.53, 95% CI 1.1-5.82, P = 0.03). Hospital length of stay was longer with OM (median 6 versus 4 d, P = 0.002).

After a decade of modern, physiology-driven care, NOM for high-grade blunt splenic injuries demonstrates a low failure rate and achieves similar adjusted mortality and major adverse outcomes compared with OM. Risk was driven primarily by injury burden and hypotension.