Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 52

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PRESSURE ULCER PREVENTION AND TREATMENT FOLLOWING SPINAL CORD INJURY

recurrent ulcer as a de novo ulcer even when it
recurs along a healed tension-free surgical
incision. This is not true for ulcers that recur
within the scar of an ulcer healed non-surgically,
which should be staged with the same stage as
the previous ulcer.
The distinction between early ulcer
recurrence (from tissue loading with incomplete
surgical healing) and late recurrence (new ulcer
formation) is key to interpreting the contradictory
literature evidence. One study stated that the
history of a surgically repaired pressure ulcer was
a marker for poor wound healing and outcome
(Allman et al., 1995). A more recent study
reported that any history of prior same-site
dehiscence or recurrence increased the rate of
long-term flap failure from 40% to 52% (Keys et
al., 2010). Other studies have found that the
success of flap closure for pressure ulcers was
not affected by previous flap reconstruction
(Foster et al., 1997; Kierny et al., 1998). A
previous flap reconstruction does not seem
necessarily to correlate negatively with any of the
surgical outcome variables if an ulcer recurs at
the same site (Goodman et al., 1999). If an
individual had multiple previous surgeries for
ulcers at different but contiguous sites, flap
reconstruction will become more difficult
(perhaps even impossible) because of the amount
of scar tissue and the lack of remaining available
flap reconstructive options. The amount of ulcerfree time achieved after surgical closure should
also factor in patient selection for subsequent flap
repair in a cost (morbidity/mortality risk, resource
utilization) versus benefit analysis. For individuals
with recurrent pressure ulcers despite multiple
previous flap surgeries, where reconstructive
surgery is no longer indicated or possible,
operative intervention (i.e., debridement) may be
required to control bioburden or treat infection as
a palliative wound management measure.
SMOKING

While there may be some controversy about
the overall impact of smoking and nicotine on the
development, healing, and recurrence of pressure
ulcers, it is well known by plastic surgeons that
cigarette smoking is associated with impaired
healing of skin flaps (Kreuger, 2001). The
proposed biological mechanisms by which
smoking impairs wound healing include
vasoconstriction, displacement of oxygen from
hemoglobin binding sites by carbon dioxide,
increased platelet aggregation, impairment of
inflammatory cell oxidative burst, reduced
collagen deposition, endothelial damage,
development of atherosclerosis, and increased

blood viscosity. Oxygen is essential in all aspects
of healing, and any condition that decreases the
delivery of oxygen to the wound is detrimental.
After smoking for just 10 minutes, the levels of
oxygen in the skin are reduced by 22-48%
(Jensen, 1991). Numerous studies have been
published establishing that smokers are at
increased risks of cardiopulmonary and woundrelated postoperative complications; one study
found that flap necrosis occurred three times
more frequently than in patients smoking one
pack of cigarettes a day compared to nonsmokers, and six times more frequently in
patients smoking two packs a day (Moller et al.,
2002).
Several studies have shown that pre-operative
smoking cessation reduces the risk of smokingassociated complications. A published review of
multiple randomized controlled trials supports
smoking cessation at least four weeks before
surgery (Thomsen et al., 2009). Taking all this
data in mind, it has been recommended that
patients be nicotine abstinent for at least four
weeks prior to flap reconstruction for pressure
ulcer repair, with some surgeons advocating for
verification using nicotine/cotinine testing.
URI NARY TRACT I NFECTI ON

Individuals with SCI have a higher than
normal risk of urinary tract infections. Due to the
risk of bacteremia and sepsis that UTIs generate,
adequate preoperative management is essential.
The difficulty is in differentiating infection from
colonization as is the case for chronic wounds like
pressure ulcers.

Postoperative Care
Clinical reports and anecdotal information
indicate that the most successful centers provide
post-operative care after flap closure based on
strict multidisciplinary protocols. These protocols
have changed dramatically in recent years,
primarily because of the significant decrease in
length of hospital stay after surgery as well as the
development of new technology. While the
specifics may differ between each facility and
across the published literature, certain
commonalities do exist: strict post-operative
pressure relief and bed rest on a pressure
redistributing support surface, graduated
resumption of activity, modification of the risk
factors for pressure ulcer development (and
recurrence), and education of the patient and the
patient's family and caregivers about pressure
ulcer vigilance (Kierney et al., 1998; Levi, 2007;
Bauer, 2008; Tchanque-Fossuo et al., 2011). In
actuality, the last two themes of risk modification
Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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