Rosen & Barkin's 5-Minute Emergency Medicine Consult (670 page)

• Immediate laparotomy may be appropriate in the acutely injured and hemodynamically unstable patient with presumed hemoperitoneum and splenic injury.
  
• Most patients with acute splenic injury either are hemodynamically stable or stabilize rapidly with relatively small amounts of fluid resuscitation.
  
• Adjunctive diagnostic procedures supplementing the physical exam should be performed early in the evaluation, followed by laparotomy when indicated by positive diagnostic findings.
  
• Gunshot wounds to the anterior abdomen are routinely explored in the OR.
  
• Stab wounds can be managed by local wound exploration, followed by US or DPL when intraperitoneal penetration is suspected.
  
• Operative vs. nonoperative management:
  
  • Patients with signs and symptoms of intraperitoneal hemorrhage, those with operative indications based on imaging//diagnostic procedures, and those who fail nonoperative management should undergo laparotomy.
    
  • Angiographic embolization is an option in hemodynamically stable patient
    
  • Splenectomy vs. splenic salvage depends on the grade of splenic injury.
    
  • >70% of all stable patients are currently being treated via nonoperative management:
    
    • Hemodynamic stability
      
    • Negative abdominal exam
      
    • Absence of contrast extravasation on CT
      
    • Absence of other clear indications for exploratory laparotomy
      
    • Absence of associated health conditions that carry an increased risk for bleeding (e.g., coagulopathy, hepatic failure, anticoagulant use, coagulation factor deficiency)
      
    • Injury grades I–III
      

• Patients >55 yr should be considered for operative management due to decreased physical tolerance to traumatic insult (splenic capsule thins with age) and reduced physiologic reserve.
  
• Embolization is relatively contraindicated in patients >55 yr due to higher failure rates in these patients.
  

• Nonoperative management of splenic injuries is considered safe:
  
  • Concerns for overwhelming postsplenectomy infection/sepsis
    

FOLLOW-UP

All patients with splenic injury require hospitalization for definitive laparotomy or observation with serial abdominal exams, serial hematocrit determinations, and bed rest.

Only asymptomatic patients objectively demonstrated not to have splenic or other traumatic injury may be discharged.

• Bhullar IS, Frykberg ER, Siragusa D, et al. Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management.
  J Trauma Acute Care Surg
  . 2012;72:1127–1134.
  
• Gomez D, Haas B, Al-Ali K, et al. Controversies in the management of splenic trauma.
  Injury
  . 2012;43:55–61.
  
• Izu BS, Ryan M, Markert RJ, et al. Impact of splenic injury guidelines on hospital stay and charges in patients with isolated splenic injury.
  Surgery
  . 2009;146(4):787–791.
  
• St Peter SD, Keckler SJ, Spilde TL, et al. Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children.
  J Pediatr Surg
  . 2008;43:191–194.
  
• Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: Spleen, liver, and kidney, validation based on the National Trauma Data Bank.
  J Am Coll Surg
  . 2008;207(5):646–655.
  

CODES

• 865.00 Injury to spleen without mention of open wound into cavity, unspecified injury
  
• 865.01 Injury to spleen without mention of open wound into cavity, hematoma without rupture of capsule
  
• 865.02 Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma
  

BASICS

• Spondylolysis:
  
  • Bony defect at the pars interarticularis (the isthmus of bone between the superior and inferior facets)
    
  • Can be unilateral or bilateral
    
  • Bilateral form has a much higher likelihood of slippage or spondylolisthesis than the unilateral form.
    
• Spondylolisthesis:
  
  • The slipping forward of 1 vertebra upon another
    
  • Spondylolysis can contribute to spondylolisthesis, which is noted in ∼5% of the population. It is 2–4 times more common in males.
    
  • Of those with spondylolysis, 50% will have some degree of spondylolisthesis develop during their lifetime, and 50% of those will be symptomatic:
    
  • Literature does not associate athletic activity with increased slippage.
    
  • Spondylolisthesis predisposes to nerve root impingement and frequently sciatica.
    
• Classification:
  
  • Type 1—dysplastic: Congenital defect of the neural arch or intra-articular facets is often associated with spina bifida occulta
    
  • Type 2—isthmic: Stress fracture from repetitive microtrauma through the neural arch
    
  • Type 3—degenerative: Long-standing segmental instability
    
  • Type 4—traumatic
    
  • Type 5—pathologic: Generalized or focal bone disease
    
  • Spondylolisthesis is divided into 4 grades based on degree of slippage (Meyerding grading system):
    
    • Grade I: Up to 25% of the vertebral body width
      
    • Grade II: 26–50% of vertebral body width
      
    • Grade III: 51–75% of vertebral body width
      
    • Grade IV: 76–100% of vertebral body width
      
  • The most common location for spondylolisthesis is L5 displaced on the sacrum (85–95%), followed by L4 on L5.
    

• Spondylolysis is one of the most common causes of serious low back pain in children, although it is most often asymptomatic.
  
• Symptoms most often present during adolescent growth spurt from age 10–15 yr.
  
• Seen commonly in athletic teens; particularly in sports involving back hyperextension (e.g., gymnastics, diving, football).
  
• Acute symptoms are related to trauma.
  

Unknown; theories include congenital pars anomalies, alterations in bone density, and recurrent subclinical stress injury.

DIAGNOSIS

• Onset often gradual, unless traumatic
  
• Often associated with feeling of stiffness or spasm in paravertebral muscles
  
• Pain in the back and proximal legs aggravated by standing and walking
  
• Sitting or forward bending relieves pain.
  
• Pain occurs after varying amounts of exercise, with standing, or with coughing:
  
  • Aggravating factors can include repetitive hyperextending movements.
    
  • Alleviating factors can include rest, although the course is variable and slow and usually requires sitting or stooping positions.
    
• Systemic/neurologic symptoms: Minimal, unless there is significant trauma or “slip.”
  

• Hyperlordotic posture:
  
  • Trunk may appear shortened.
    
  • Rib cage approaches iliac crests.
    
• Hamstring tightness:
  
  • Knees flexed to allow patient to stand upright
    
• Only “typical” finding is 1-legged hyperextension:
  
  • Standing on 1 leg and leaning backward reproduces pain on ipsilateral side.
    
• Palpation may reveal step-off with a prominent spinous process of L5 in significant spondylolisthesis.
  
• Neurologic exam is usually normal:
  
  • If abnormal, pain and sensorimotor loss is in a dermatomal distribution.
    
  • Consider herniation or spondylolisthesis.
    

• Spondylolysis in a child <10 yr is rare; these patients should be watched for the following:
  
  • Constant pain lasting several weeks
    
  • Pain occurring spontaneously at night
    
  • Pain that interferes repeatedly with school, play, or sports
    
  • Pain associated with marked stiffness, limitation of motion, fever, or neurologic signs
    
  • Pain at the lumbosacral junction
    

There are no required lab studies.

• Lumbosacral spine radiographs:
  
  • Lateral and oblique radiographs of spine most helpful.
    
  • Spondylolysis will manifest as a radiolucent defect in the pars interarticularis, visible as a “collar” or “broken neck” on the oblique view “Scottie dog”
    
  • Secondary radiographic signs may include sclerosis of the contralateral pedicle and spina bifida occulta at the level of the spondylolysis.
    
  • Majority (80–95%) found at L5–S1 level, 15% at L4–L5.
    
  • Spondylolisthesis will manifest as forward slipping of one vertebral body on another (seen on lateral view).
    
• Single photon emission computed tomography (SPECT)—better specificity for linking back pain to spondylolysis.
  
• CT scan:
  
  • Pathology more clearly demonstrated than on plain films
    
  • Can identify other spinal pathology
    
  • Plays an important role for orthopedics in management decisions through identification of new stress fractures and healing of old stress fractures.
    
  • If a CT scan is obtained in the ED, sagittal reconstructions should be performed and the CT scanner should be at minimum a 16-slice scanner.
    
  • Outpatient evaluation unless history of recent trauma.
    
• MRI—exact role not yet clarified in literature:
  
  • Useful for defining nerve root impingement and central canal and neuroforaminal narrowing.
    
  • May be useful in the assessment of acuity of abnormality.
    
  • Can identify alternate pathologic diagnoses.