Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 50

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PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

silver- or iodine-based products for local wound
care during the pre-operative period.
N U T R I T I O N A L STAT US

The healing of any wound, including surgical
incisions, requires adequate resources both
caloric and protein. This will help ensure that the
body is in an anabolic (protein-building) condition
and not in a catabolic state (protein-destroying)
state. To augment clinical findings of malnutrition
(decreased subcutaneous tissue, nail/hair changes,
decreased body mass index, etc.) biochemical
data such as serum albumin have been used for
objective assessment of nutritional status. While a
national VA surgical risk study found that
decreasing levels of serum albumin are associated
with increased morbidity and mortality rate in
general surgery, non-cardiac thoracic surgery,
and orthopaedic surgery cases (Gibbs J et al.,
1999), recommendations for specific serum levels
prior to pressure ulcer closures have not been
truly evaluated for their significance on
postoperative healing.
Conventional wisdom is that malnutrition
should be corrected through the administration
of protein and caloric supplementation (and
micronutrients such as vitamins and minerals to
correct specific deficiencies) to achieve positive
nitrogen balance prior to surgical repair of
pressure ulcers. Improvement of nutritional status
can be monitored via the weekly measurement of
serum pre-albumin and transferrin, both of which
have much shorter half-lives than albumin. In
reality, it is often difficult to attain positive protein
balance and a normal serum albumin level above
3.5g/dL due to the increased protein consumption
by the sustained chronic inflammatory state found
with most chronic pressure ulcers (Scivoletto et
al., 2004). While a pilot study found that the
anabolic steroid oxandrolone may stimulate
pressure ulcer healing through its metabolic
effects, this was not borne out by a follow-up
multicenter trial (Bauman et al., 2013). In fact, it
has been shown that the metabolic abnormalities
found with large pressure ulcers are most reliably
corrected after surgical intervention with
debridement and flap coverage (Scivoletto et al.,
2004; Larson et al., 2012).
B O W E L M A N A GE ME NT

The maintenance of healthy and noninfected
tissue is essential in the management of pressure
ulcers. Clearly this entails prevention of
contamination by fecal soilage. If someone with
SCI and pressure ulcers does not have volitional
control of defecation and experiences fecal
incontinence, a bowel routine should be
implemented as described in Neurogenic Bowel

Management in Adults with Spinal Cord
Injury. March 1998. Some clinicians strongly
recommend a colostomy to achieve a cleaner
perineal milieu and contend that the elimination
of chronic constipation and complex bowel care
regimens improves overall quality of life (Munck
et al., 2008). Arguments used against elective
stoma creation suggest that it is associated with
significant morbidity and complication rates,
however, modern operative techniques using
minimally invasive procedures have greatly
reduced the morbidity and mortality rates
compared to historical reports (de la Fuente et
al., 2003).
Fecal incontinence must be controlled before
surgery (Lewis, 1990). Preoperative evacuation of
the colon and rectum, especially on the morning
of operation, with the use of oral laxatives and
enemas will reduce the risk of early intraoperative
and early postoperative wound contamination.
Again, temporary bowel diversion via a colostomy
may be indicated for individuals with a pressure
ulcer in close proximity to the anus and is
performed routinely at some institutions (Rubayi,
1999). This procedure will minimize the risk of
flap compromise and infection after surgery and
overall healing complications, since the healing of
surgical incisions is impaired by fecal exposure.
SPASTI CI TY AND CONTRACTURES

Hyperreflexia secondary to upper motor
neuron lesions may be helpful in preventing
muscle atrophy and improving the ability to
transfer to and from bed, but severe spasticity
precludes surgery (Herceg and Harding, 1978).
Muscle spasms may be sufficiently severe enough
to rip open fresh surgical incisions (Bauer, 2008).
Therefore, spasticity control should be optimized
before surgical intervention for pressure ulcers.
Oral pharmacological treatment includes the
use of baclofen, tizantidine, and occasionally
benzodiazepines. Muscle blocks with botulinum
toxin and nerve blocks using alcohol or phenol
can be effective for targeting specific spastic
muscle groups. More invasive treatments may
include placement of an intrathecal pump for the
administration of baclofen and as a last resort,
dorsal rhizotomy.
Severe flexion joint contractures that result in
the tightening of muscles and joint capsules and
the limiting of range of motion may aggravate
development of pressure ulcers and also promote
recurrence. These contractures can limit patient
positioning and make relieving pressure on bony
prominences difficult for caretakers (Bauer,
2008). Contractures of the lower extremities are
especially prone to the development of pressure
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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