儿童脾脏挫裂伤影像学分级及保守治疗的新认识

New opinion on radiological grade and conservative treatment of children splenic injury

目的 虽然美国创伤外科学会在1994年制定脾脏挫裂伤的影像学分级,且已经被广泛应用,但在国内很少有中心对儿童脾挫裂伤进行分级.本文通过回顾性分析儿童创伤性脾破裂伤影像学分级与临床诊治特点,探讨儿童脾挫裂伤影像学分级在临床治疗中的作用,及保守治疗过程中的难点.方法 收集2008年8月至2014年12月复旦大学附属儿科医院收治的急性创伤性脾破裂伤患儿的临床资料,根据影像学资料进行回顾性影像学损伤分级,同时对患儿临床治疗过程中的禁食、抗生素使用、卧床休息等情况进行分析.结果 本组病例共纳入59例,占同期腹部损伤患儿的29.3%（59/201）;男41例,女18例;年龄中位数9.5岁（3个月~16岁）;跌倒/坠落伤23例,交通伤27例,其他类型损伤9例.影像学分级Ⅰ级5例,Ⅱ级26例,Ⅲ级21例,Ⅳ~Ⅴ级6例,不明确1例.其中25例合并其他脏器损伤.临床治疗包括禁食、绝对卧床、抗生素预防感染等.治疗和随访过程中有49例患儿行2次以上CT检查.59例均行保守治疗,1例中转手术,术后无相应并发症,余58例均保守治疗成功.结论 在严格掌握适应证和密切观察伤情变化的条件下,对儿童创伤性脾损伤行保守治疗较为安全.发病早期行影像学分级可能有助于临床判断病情,减少患儿放射性暴露.

Objective Radiological grade of splenic injury was seldomly used in China trauma center now,though it had been established in 1994 by American Association for Surgery of Trauma （AAST） and widely used.The present study is aimed to analyze the imaging grade and clinical characteristics of traumatic splenic rupture in children,discuss the feasibility of conservative treatment,and the role of radiographic grading during clinical treatment.Methods Information （including age,gender,severity based on radiological findings,treatment strategies,and clinical outcome） regarding 59 hospitalized splenic injury patients whose injuries occurred between 2008 and 2014 was retrospectively analyzed.Results Between 2008 and 2014,59 pediatric patients with splenic injury were treated in our institution.Median age was 9.5 years （range,3 months to 16 years）.Of all patients,41 （69.5%） were male.The injuries were primarily caused by traffic crash （45.7%）,stumbling/falling from a height （38.9%）.According to AAST,5 cases were grade Ⅰ,26 patients grade Ⅱ （44.1%）,and 21 cases grade Ⅲ （35.6%）,6 over grade Ⅳ,and only one was unclear.Of all patients,25 cases were with the other organs complications.All patients underwent fasting,bed rest,and antibiotics.Only 1 case was transferred to operation during the conservative treatment.Forty-nine patients underwent with CT scan over 2 times.Conclusion Imaging classification helps guide clinical treatment.Conservative treatment is feasible for traumatic splenic injury in children.Early imaging classification of splenic injury may be helpful in clinical judgment,and reduce children radiation exposure.