Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 48

48

PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

those that are associated with ulcer recurrence
after surgery, patient selection and pre-operative
preparation are paramount (Tchanque-Fossuo et
al., 2011). Successful surgical repair of pressure
ulcers is largely determined by adherence to
appropriate dressing change routine and
pressure-relief protocol including the use of
appropriate pressure re-distributing support
surfaces, maintenance of nutritional health, and
management of co-morbid medical conditions.
The surgical procedure is often time consuming
and may be associated with significant blood loss
and anesthetic challenges (Bauer, 2008).
Successful repair does not end in the recovery
room post surgery. It is dependent on personal
behaviors and active participation by the patient.
Individuals with SCI must exhibit self-motivation
to avoid deleterious actions and comprehend the
pathogenesis of the ulcers to avoid redevelopment
(Stal et al., 1983). It is difficult to measure
subjective characteristics such as self-motivation,
comprehension, quality of life, and probable
individual cooperation. Clinicians must use
clinical judgment with input by the entire
interdisciplinary health care team in making
treatment decisions.
The operative plan requires debridement
immediately prior to closure even for wounds that
appear clean. All contaminated and heavily
scarred tissue should be removed, including
partial ostectomy of exposed bone, producing as
fresh a wound as possible. All bony irregularities
that would cause extreme pressure points should
be eliminated (Tchanque-Fossuo et al., 2011).
Since pressure ulcers represent tissue loss and an
overall tissue deficiency, reconstruction with the
interposition of a well-vascularized flap is the
reconstructive strategy of choice most of the
time. To reiterate, there is no strong evidence
favoring the use of any specific anatomic flap
(since every ulcer is unique with its own
challenges); however, in general most surgeons
prefer to close ischial ulcers with a leg flap first
(tensor fascia lata, posterior thigh, hamstring,
gracilis), sacral ulcers with a gluteal flap, and
trochanteric ulcers with a tensor fascia lata or
vastus lateralis flap (Tchanque-Fossuo et al.,
2011; Bauer, 2008). In all cases the closure
should be tension-free with closed-suction
drainage for prevention of fluid collection under
the flap.

Preoperative Assessment
20. Address the following factors to enhance the
effectiveness of pressure ulcer surgery:


Presence of osteomyelitis



Wound bioburden



Nutritional status



Bowel and bladder management



Spasticity and contracture



Heterotopic ossification



Comorbid medical conditions



Anesthesia



Previous ulcer surgery



Urinary tract infection



Smoking cessation

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

Several conditions need to be optimized or
corrected prior to operative repair of pressure
ulcers. Surgery should be delayed until the
individual is in optimum condition.
OSTEOMYEL I TI S

Bacterial infection of bone occurs by
introduction of microorganisms via hematogenous
seeding, contiguous spread from surrounding
structures, or direct inoculation from surgery or
trauma. Osteomyelitis associated with pressure
ulcers most likely results from bacterial
contamination of exposed bone in category/stage
IV ulcers, or from translocation from the ulcer
bed of a category/stage III ulcer. Clinical staging
of adult osteomyelitis (as opposed to pediatric
osteomyelitis which predominantly occurs by
hematogenous seeding) based on anatomic type
was classical described by Cierny in 1985, and
has hence been called the Cierny-Mader
Classification System (Cierny, 2003). This system
divides osteomyelitis into four anatomic types:
Type I - medullary (central), Type II - superficial
(surface), Type III - localized (full-thickness of
cortex), and Type IV - diffuse (circumferential
disease). Osteomyelitis arising from deep pressure
ulcers is mostly Type II and may only rarely
develop into Type III or Type IV if left untreated
for a prolonged time (Darouiche et al., 1994).
The traditional treatment of osteomyelitis with 4-6
weeks of parenteral antibiotics was established by
extrapolation from animal models in 1970s and
1980s (Fraimow, 2009). However, there is more
recent evidence that in the absence of sepsis, the
osteomyelitis associated with pressure ulcers is of
limited clinical consequence (Türk, 2003) and
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