A Primary Care Provider’s Guide to Prevention and Management of Pressure Injury and Skin Breakdown in People With Spinal Cord Injury

A 38-year-old male with a 14-year history of C6 complete tetraplegia returns to your clinic to report that, during his last bowel care, his home care nurse found a dark purple spot on his coccyx that he wants you to look at. He had a history of a small sacral “bed sore” at the time of his initial spinal cord injury (SCI), but it healed during his rehab. He had no skin breakdown from then until now. Nothing has changed in his health or daily routine that he can think of, and he has no idea what caused the wound.

Skin breakdown, including burns and pressure injuries (PrIs), are devastating complications of SCI. It decreases community integration and quality of life while increasing risk of complications, including soft tissue infections, osteomyelitis, sepsis, and death. Managing the multiple factors promoting the development and chronicity of PrIs requires a multidisciplinary approach.^1,2  A treatment plan for wound care should be developed with the person with SCI, which—with contributing factors in mind—may include palliative wound care.³  The development of an interdisciplinary team for persons with SCI who live in rural areas or lack access to transportation for medical appointments may require significant effort by the primary care provider (PCP). In addition, lack of access to specialized SCI care increases risk of PrI development,¹  and long-distance travel via wheelchair or gurney can create or worsen PrIs.² 

Assessment of skin problems in individuals with SCI requires adequate time for examination. Skin breakdown is often caused by multiple factors and requires PCPs to familiarize themselves with the individual’s overall health, mobility, and social support. PCPs should plan for a comprehensive history and full body evaluation whether or not the patient has wounds. Before the patient’s visit, PCPs should try to confirm the patient’s mobility needs to permit planning for transfers in the clinic. Also, the patient should bring in a list of any durable medical equipment used at home including the name, model, and vendor, if available.

The ultimate management of skin breakdown in people with SCI is prevention. This requires familiarity with the individual’s level of SCI, functional ability, and burn and pressure injury risk factors. An exploration of the patient’s personal goals of care regarding their skin and their understanding of their overall health as well as the identification of barriers to implementing health care plans will optimize patient care.³ 

Although there are risk assessment tools⁴  to help identify a person’s likelihood of developing PrIs, more than 200 risk factors are known to contribute to PrI development.⁵  See Table 1 for factors contributing to overall health and PrI prevention.^6,7 

The cornerstone for skin breakdown prevention in persons with SCI is education that takes into account the individual’s preferences and life goals. The team should regularly assess the person’s overall perception of quality of life and self-efficacy; this perception may be an indication of the patient’s ability and willingness to implement preventive measures (Table 2), such as performing regular pressure relief and skin checks, checking equipment and wheelchair cushions, maintaining nutrition, achieving moisture control, and avoiding smoking.^8–10 

PrIs occur over bony prominences or surfaces that experience pressure from equipment, body parts, or decreased mobility. This includes but is not limited to the ischial tuberosities, sacrum, heels, hips, knees, ankles, spine, back of the head, and scapulae. PrIs can occur due to prolonged pressure, high pressure for short periods (e.g., falls), or pressure in combination with shearing. They should be staged according to the National Pressure Injury Advisory Panel (NPIAP) staging system¹¹  to document their severity. Refer to NPIAP for full definitions of the different stages of PrI (https://www.npiap.com/). Table 3 provides abridged descriptions of the stages.

Wound assessment should begin with the identification of the type of wound: PrI, bacterial or fungal infections, venous stasis, arterial insufficiency, diabetic, incontinence dermatitis, burns, or other lesions (e.g., melanoma). Wounds must be visually inspected, palpated, and assessed for malodor. Wound assessment should include location, size, stage, presence of eschar, slough, granulation tissue, epithelialization, appearance of wound margins, exudate type and amount, and state of peri-wound tissue.

Wounds should be photographed and measured in a consistent manner at each visit.⁶  Linear wound measurements of length and width may be obtained using cotton-tipped swabs to determine the greatest vertical distance and the greatest horizontal distance. When describing specific characteristics, such as tunneling or undermining, a clock is a useful reference. For example, “there is undermining from 1 o’clock until 7 o’clock, deepest is 3 cm at 4 o’clock.”

Burns should be classified as superficial, superficial partial thickness, deep partial thickness, or full thickness. Fourth degree burns extend into deep tissue below the dermis including muscle, adipose, tendon, and bone.¹² 

The wound bed needs to be cleaned prior to assessment. Assessment can be methodized using the TIME framework (Tissue, Infection/Inflammation control, Moisture imbalance, and Epithelial advancement)¹³  (see Table 4). This method helps define active wound issues, aids with developing a wound care plan,¹⁴  and tracks wound healing or worsening when combined with wound measurements. Note that wound margins are considered normal if the free edges gradually meet across the wound bed.

Successful treatment of skin breakdown requires optimal wound bed preparation, pressure offloading, nutrition, durable medical equipment, and access to surgical specialists, if needed. See Figure 1 for a suggested wound management algorithm.

To optimally treat a new or chronic wound, the primary care team must engage persons with SCI and their support network to investigate the factors (Table 1) driving development and persistence of the wound—particularly noting positioning on support surfaces and in wheelchair seating systems—and provide them with appropriate wound care to promote wound healing and aid prevention. When comorbid conditions promote wound chronicity (diabetes, tobacco use, arterial or venous insufficiency, and poor perfusion due to unrelieved pressure), a palliative rather than a curative wound treatment plan may be needed.^3,6,7 

The wound stage or severity is used to develop the wound treatment plan. Healing full-thickness wounds can be challenging and may require spe cialty consultation. Unmanaged biofilm amplifies wound inflammation, leading to breakdown of newly formed extracellular matrix and promoting wound chronicity. Sharp debridement is used to remove the necrotic debris when eschar is present. Debridement should be avoided for stable, dry, nonfluctuant eschar on the heels or areas with little tissue coverage over bony prominences. These areas should be left intact, painted with povidone iodine, and kept dry. Cautious wound debridement may be performed in the clinic in people with SCI who lack pain sensation, taking care to avoid triggering autonomic dysreflexia. If the wound bed is covered with loose slough or biofilm, a wound specialist should be consulted regarding enzymatic or autolytic debriding agents and anti-biofilm surfactant cleansers. Once the wound bed is optimized, wound healing occurs if the wound bed is kept clean, moist, and at body temperature.

Selection of a dressing for the wound is guided by wound environment needs, support for wound care treatments, and cost (see Table 5). Wound dressings need to be cautiously removed to avoid further injuries from pressure or adhesive stripping of fragile epidermis. Wet-to-dry gauze dressings are rarely recommended for people with SCI due to the risk of mechanically debriding both necrotic and healthy tissue as well as creating a nidus of a pressure when the gauze compresses. Frequency of wound care is based on product recommendation, amount of drainage or infection, and availability of wound care dressing assistance. For deep but uninfected wounds, wound specialists may order negative pressure wound therapy to remove biofilm and control moisture, stimulate granulation tissue formation, and promote wound contraction. The wound should be assessed and measured every 1 to 2 weeks. If wound healing is not improved after 1 month of treatment, it should be re-evaluated and the treatment adjusted. If the wound is worsening, infection or poor adherence to treatment recommendation may be the cause. After re-evaluation, a referral to a wound care specialist should be considered.^3,6,7 

Depending on the location and cause of a PrI, evaluation of the appropriateness of the person’s durable medical equipment may be needed. This will likely require the provider to find community support with a physical medicine and rehabilitation physician, physical or occupational therapist, or wheelchair seating specialist. Because the care needs of people with SCI for PrI prevention and treatment can be complex, a multidisciplinary team is the standard of care.

Acute and chronic osteomyelitis may contribute to nonhealing of stage 4 PrIs and has been found in 25%–47%^15,16  of nonhealing severe PrIs. It can also complicate the plan of care if flap closure is desired. Imaging with radiographs, three-phase bone scan with SPECT, MRI with contrast, or tagged white blood cell (WBC) scan with SPECT are useful diagnostic tools. Definitive diagnosis relies on bone biopsy and culture. Treatment of osteomyelitis should include debridement of infected bone and 6 weeks of appropriate antibiotics.^3,6,7 

Consideration for surgical management including flaps and primary closures should be coordinated with an interdisciplinary team to ensure that the person’s condition is optimized before surgery including tobacco cessation, durable medical equipment including seating check for dysfunction, stable psychological state, and ability to complete bed rest after flap. The postoperative care plan will likely require an extended care facility stay for supported bed rest followed by a progressive seating protocol to minimize the risk of flap failure.⁶ 

Chronic wounds can lead to multiple complications including bacteremia, sinus tracts and abscesses, septic arthritis, endocarditis, fistulas, and joint contractures. Squamous cell carcinoma, or Marjolin ulcers, can occur in long-term (years) chronic wounds and can be identified by increased pain, discharge, and bleeding with verrucous hyperplasia.⁶ 

Your clinic nurse used your floor-based lift to transfer the patient to an exam table, and you identified a coccygeal deep-tissue pressure injury. You could not find a cause on initial assessment and referred him emergently to a wound care clinic. He returned to see you after 2 weeks and reported trying to do some bed rest, but he continued to work at his desk job about 6 hours per day with frequent pressure relief. The wound evolved to an unstageable PrI, which the wound care clinic treated with a topical enzymatic debriding agent. After a month, the unstageable injury did not improve. The patient was referred to a wheelchair seating clinic, where the contoured hybrid gel and foam cushion was found to be positioned backwards inside the cushion cover. In this orientation, the ridge that should separate his thighs pressed up against his coccyx. Further questioning revealed that a new home health aide started working for him about 2 months ago, around the time the wound appeared. After correcting the wheelchair cushion orientation and surgical debridement, the wound was found to be a shallow stage 4 PrI, and it healed after 3 months of negative pressure wound therapy.

The successful prevention and treatment of wounds in people with SCI requires an interdisciplinary approach in order to minimize risk factors, remove identifiable causes, and promote wound healing. Infection should be treated with input from infectious disease specialists. Consideration for specialized surgical management should be coordinated with the interdisciplinary team. Unmanageable comorbid conditions may promote wound chronicity requiring a palliative treatment approach.

The authors have no conflicts of interest to report.