Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 46

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

61 individuals with pressure ulcers, 52 of them
had confirmed histopathologic diagnosis of
osteomyelitis, and the value of some common
tests in making the diagnosis of osteomyelitis
(namely, white cell count, erythrocyte
sedimentation rate, plain X-ray, Tc99 M bone
scan, CT scan, and needle bone biopsy) was
evaluated (Lewis et al., 1988). The most practical
and least invasive evaluations involved a
combination of white blood count, sedimentation
rate, and two-view pelvic X-ray. This protocol was
sensitive in 89% and specific in 88%. Bone scans
and CT scans were expensive and were not found
to be very sensitive. The most useful single test
was needle bone biopsy, with a sensitivity of 73%
and a specificity of 96%. MRI scanning may have
an emerging use in diagnosis and evaluation of
the extent of osteomyelitis. It may show bone
necrosis in the presence of chronic osteomyelitis.
However, in the absence of bone necrosis, the
diagnosis of osteomyelitis by MRI scanning
remains problematic. Furthermore, it has the
advantage of showing soft tissue concerns related
to pressure ulcers and osteomyelitis, e.g., deep
abscess, significant undermining/tunneling.
Bone biopsy remains the definitive method
for diagnosis and allows identification of the
offending organism (Sugarman, 1987). When
osteomyelitis is confirmed by bone biopsy,
debridement may be necessary, in conjunction
with appropriate postoperative antibiotics which
are generally continued for 6 weeks.
CARCINOMA

Long-standing ulcers, usually present for 20
years or more, can develop a squamous cell
carcinoma, known as a Marjolin's ulcer
(Dumurgier et al., 1991; Schlosser et al., 1956;
Treves and Pack, 1930). Warning signs include
pain, increasing discharge, bleeding, foul odors,
and verrucous hyperplasia. A tissue biopsy is
essential when suspected. Metastasis to inguinal
nodes is common (Berkwits et al., 1986).
A B N O R M A L W OUND HE A LING

Full-thickness wounds heal by a process of
granulation, epithelialization, and contraction.
Granulation tissue, normally granular and uneven,
indicates the growth of new capillary loops and a
matrix of collagen and ground substance in the
wound base (Flanagan, 1998). Healthy
granulation tissue is bright red, moist, and shiny;
rapidly proliferates; and does not bleed easily
(Flanagan, 1998).
Granulation tissue extending above the
wound margins is termed hypergranulation. This
"exuberant" tissue delays wound healing by
retarding epithelialization (Kiernan, 1999). The

etiology of this clinical finding is unclear. Several
methods are used to manage hypergranulation
including use of silver nitrate sticks, silver
dressings, sharp debridement, and and semiocclusive or nonocclusive dressings that dry the
wound. In a prospective, noncontrolled,
correlational study, Harris and Rolstad (1994)
found a 2mm significant decrease in height of
granulation tissue within 2 weeks of using a
polyurethane foam dressing to treat
hypergranulation (N=12 wounds).
NUTRI TI ON

See nutrition section under recommendation 8.
MEDI CATI ON

Corticosteroids affect almost every phase of
wound healing. However, doses greater than 40
mg per day of prednisone are needed to adversely
affect fibroplasia and collagen remodeling when
taken for more than 3 days (Karukonda 2000).
Immunosuppressants, such as azathioprine,
cyclophosphamide, cyclosporine, and
methotrexate, in general have no significant
inhibition of wound healing (Karukonda 2000).
SUPPORT SURFACES

Inappropriate, ineffective, or worn-out support
surfaces can prevent pressure ulcers from healing
(Wilczweski et al., 2012).
TRANSF ERS

Poor transfer technique with inadequate body
clearance over obstacles, such a wheelchair tire,
can result in friction and shear pressure damage
to tissues, including existing ulcers, impacted
during the transfer. Areas of the body most
commonly affected by poor transfer technique
include the ischium, trochanters, and sacrum.
NONCOMPL I ANCE

Noncompliance to recommended best
practices such as the regular performance of
pressure redistribution, position change, use of
pressure relieving support surfaces, and proper
transfer technique can all contribute to the nonhealing of pressure ulcers regardless of the
intensity of treatment.

Treatment - Surgical
Referral for Pressure Ulcer Surgery
19. Refer individuals with deep category/stage
III and category/stage IV pressure ulcers for
operative intervention. For persons deemed
appropriate candidates for surgical
reconstruction, adhere to the following
tenets of surgical treatment:

Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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