Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 47

CLINICAL PRACTICE GUIDELINE

Reverse any pressure ulcer risk factor if
possible (e.g., impaired nutritional status)
and address pre-op medical risk.

Prior to surgery, treat osteomyelitis or
cellulitis. This may need to be combined with
excision of infected bone during surgery.

Fill dead space and enhance the blood
supply of the healing wound by mobilizing
well-vascularized soft tissues flaps.

Contour bony prominences to yield larger,
flatter surfaces to augment pressure
distribution.

Reconstruct soft tissue defects with large
regional pedicle flaps, placing suture lines as
far away from the area of direct pressure as
possible and with minimum tension. Avoid
encroaching on adjacent flap territories.

Preserve options for future potential
breakdowns.

(Scientific evidence-I, III, V; Grade of recommendation-A;
Strength of panel opinion-Strong)

Achieving a successful outcome after surgical
treatment of a pressure ulcer depends on proper
patient selection, pre-operative optimization,
operative procedure selection, post-operative
management including graduated mobilization,
and a supportive post-hospitalization program.
The best approach to accomplish these objectives
is through a multidisciplinary team. A
comprehensive, interdisciplinary protocol for the
surgical management of pressure ulcers is
strongly recommended. This protocol includes
in-depth assessment of medical status, i.e.,
co-morbidities/medical conditions, thoughtful
planning for specific surgical procedures based
on anatomical area and size of soft tissue defect,
consideration of underlying bony anatomy, and
appropriate follow-up care. A definitive set of
criteria for the selection of patients for surgical
repair of pressures ulcers does not exist, however,
several articles with decision guidelines have been
published (Sørensen et al., 2004; Bauer, 2008;
Tchanque-Fossuo, 2011). In general, indications
for surgery should be strict and treatment goals
realistic with the ultimate goal of sustained
improvement of quality of life.
Just as there are no specific criteria for
selecting patients for surgery, there is no
definitive algorithm to determine which flap to
use for pressure ulcer repair. In general, the least
demanding procedure with the greatest potential
for successfully achieving the agreed upon preoperative goals should be preformed, based on
anatomic location, comorbidities, and

psychosocial analysis. Myocutaneous and
fasciocutaneous flaps have superior success rates
(Bauer, 2008). Regardless of selection, the flap
should be as large as possible with placement of
suture lines away from areas of direct pressure;
flap design should allow for future re-mobilization
and should not violate adjacent flap territories,
both of which will preserve all future options for
coverage of subsequent ulcers (Foster et al.,
1997). In addition, the surgeon should be flexible
and plan for several alternate flaps to
accommodate unexpected findings in the
operating room.
Goals of surgical intervention include:
* Restoration of skin integrity and function
* Elimination of unstable scar tissue
* Recontouring of bony prominences to improve
soft tissue pressure distribution
* Diagnosis and treatment of osteomyelitis
* Reduction of healing time
* Reversal of chronic inflammatory state and
restoration of anabolic homeostasis
* Prevention of progressive secondary
amyloidosis and renal failure
* Prevention of future malignant transformation
of ulcer (Marjolin's ulcer)
* Improvement of hygiene and appearance
* Reduction of health-care costs
In general, category/stage I and II pressure
ulcers can be treated non-surgically, while
category/stage III and IV ulcers are more likely to
require surgical intervention to achieve closure
and healing. The high recurrence rates after
pressure ulcers are allowed to heal by secondary
intention (spontaneous healing) and long duration
to achieve complete healing are often cited as
reasons that surgical closure for category/stage III
and IV ulcers may be the most appropriate. Some
clinicians argue that the recurrence rate after
surgical closure is high as well, however, this is
very difficult to assess since the recurrence rate
after surgical repair of pressure ulcers reported in
the literature across multiple studies ranges from
19-90% (Tchanque-Fossuo et al., 2011). The truth
of the matter is that there is a significant
recurrence rate whether a pressure ulcer is healed
surgically or non-surgically (Guihan et al., 2008).
These data indicate that obtaining pressure ulcer
closure and preventing any recurrence is not
always an achievable goal in all patients.
Because the risk factors that predispose the
development of pressure ulcers are the similar to

Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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