Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 51

CLINICAL PRACTICE GUIDELINE

ulcers on the trochanters, knees, and ankles.
When contractures are severe, preliminary flexor
tendon releases should be considered; however,
these contractures should not necessarily be
totally released because of the risk of flail
extremities and vascular compromise from
extreme shortening of vein, artery, and nerves
across the contracted joints (Haher et al., 1983).
H E T E R O T O P IC OS S IFICAT ION

Heterotopic ossification is a specific cause of
contracture that may develop in the knees,
shoulders, elbows, hips, and spine and may
restrict joint mobility, aggravating the propensity
to develop pressure ulcers due to the limited
ability to adopt appropriate supine and sitting
postures for effective pressure distribution.
Diagnostic findings include elevated alkaline
phosphatase and evidence on X-ray and triplephase bone scan or on computerized tomography
(Bressler et al., 1987). Mature heterotopic
ossification can be removed to restore joint
motion, but removal of immature bone may result
in increased risk of recurrence of heterotopic
ossification. Extensive bone resection may lead
to considerable blood loss (Rubayi et al., 1992).
As is the case with uncontrollable muscle spasms
and joint contractures, heterotopic ossification
can affect seating positioning and range of
motion. It may increase the risk of pressure ulcer
development and affect treatment options. Its
impact must be assessed prior to surgical
intervention.
Heterotopic ossification may also be involved
within a pressure ulcer itself. One of the proposed
stimuli for the formation of heterotopic ossification
is inflammation, a condition intimately involved
with chronic wounds like pressure ulcers. The
ectopic bony tissue can create abnormal pressure
points and may be the nidus of osteomyelitis. In
the operating room, heterotopic ossification may
be encountered during pressure ulcer repair,
ranging from small spicules to ankylosis across a
joint. As much of the heterotopic bone should be
removed as possible.
C O M O R B I D C ONDIT IONS

Cardiovascular disease, pulmonary disease,
peripheral vascular disease, and diabetes have all
been implicated as factors contributing to poor
wound healing. Neither one nor a combination of
these conditions was found to correlate
significantly with a poor outcome of surgical
closure in one study which looked at them,
however (Goodman et al., 1999). Nonetheless, all
medical comorbid conditions must be addressed
and optimized in order to minimize surgical and
anesthetic risk prior to any operation.

ANESTHESI A

Airway management and positioning is a
challenge in the operating room. Because the
majority of pelvic pressure ulcers occur on the
dorsal surface of the body, ensuring adequate
surgical exposure necessitates placing the patient
in a prone position, and often flexed in order to
achieve tension-free closure of incisions. General
anesthesia with endotracheal intubation is
typically required for airway control and to
mitigate aspiration and brochospasm, and to
maintain proper patient positioning on the
operating table.
The administration of anesthesia is further
complicated by potential autonomic dysfunction
common with persons with SCI, which may
manifest as bradycardia and hypotension or
tachycardia and hypertension depending on level
of injury and whether or not sympathetic tone is
preserved. In addition, the paralytic agent
succinylcholine should not be used in patients
with SCI as there is a lifetime risk of serious
hyperkalemia. These factors mandate that
anesthesia be administered by experienced
personnel, most often found in specialized SCI
centers (Bauer, 2008).
PREVI OUS PRESSURE UL CER SURGERY
( RECURRENCE)

An analysis of pressure ulcers that occur after
previous surgical closure, specifically at the same
anatomic location, is difficult because there is no
clear consensus on the definition and natural
history of these recurrent ulcers. Do these ulcers
arise de novo or do they represent incomplete
surgical healing? One can assume that early
recurrences are due to incomplete healing and
late recurrences are separate entities from the
previous ulcer, but what time period is used to
define early versus late? Late ulcer recurrence has
been associated with unmodified patient factors
such as spasticity, pressure relief behavior, and
psychosocial status and not with surgical flap
design (Bates-Jensen et al., 2009; Keys et al.,
2010).
How does one stage ulcers that occur at the
same location as a previous ulcer closed
surgically staged? Presumably all of the ulcerous
and scar tissue was excised at the time of the
prior operation with correctly performed
approximation of incisional edges resulting in the
reconstitution of normal anatomic tissue layers.
This is not the case for ulcers that recur at
locations where a previous ulcer was allowed to
heal by secondary intention with scar tissue. If
the fascial layer was re-established with use of a
myocutaneous or faciocutaneous flap for ulcer
repair, then it should be appropriate to stage the

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Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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