A Retrospective Cohort Study of Incidence, Progression and Management of Pressure Ulcers in Spinal Cord Injury Patients in a Tertiary Care Spinal Cord Injury Center

Introduction

Currently, the NPIAP (National pressure injury advisory panel) defines a pressure injury as localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device [1]. PUs are common among individuals with a spinal cord injury (SCI) due to varying degrees of sensory and motor impairment. PUs occur when the external pressure exceeds the venous capillary closing pressure (8-12 mm Hg) & the capillary occlusion pressure (32 mmHg). While supine the sacrum, heel, and occiput bear pressures of 40-60 mm Hg. When prone, the chest and knees absorb about 50 mm Hg pressure. In the sitting position the ischial tuberosities bear pressures of up to 100 mm Hg. These locations are more prone to developing pressure sores [2–5].

Some Retrospective studies have reported the incidence of PUs among SCI in-patients as ranging up to 69.2% [6]. Other studies have reported an incidence ranging from 31.5 to 56% [3,7]. One prospective cohort study described a prevalence of 36.5% during the acute phase immediately after sustaining injury, and 39.4% during the initial rehabilitation [9]. The hip and buttock regions are known to account for up to 70% of all pressure injuries, with ischial tuberosity, trochanteric, and sacral locations being most common [10]. Muscle tissue is known to be especially susceptible to pressure injury [11]. The goal of our study was to study and statistically analyze PU characteristics in SCI patients right from the Date of injury, through the post operative period, on admission at this center and during the in-hospital post admission stay at this center.

Patients and Methods

A total of 79 admitted patients were studied during the period from 26 Oct 2022 till 27 Jun 2024. 36 patients were studied retrospectively from 30 May 2018 onwards (date of injury of longest admitted patient). 43 patients in the studied population were admitted in the center after the start of the study. NPIAP guidelines were meticulously enforced for all admitted patients. Prior to admission all 79 patients had already undergone Neurosurgery for spinal stabilization at various tertiary care centers in India, this period was defined as Acute phase of injury (Pre hospital, Neurosurgery, emergency care). After admission at this center, they were deemed to be in the Rehabilitation phase. Only those in-hospital-SCI patients were included in the study whose historical clinical records had been meticulously maintained by referring hospitals as per NPIAP guidelines. Patients admitted with spinal injuries without cord involvement and those whose clinical history had been recorded in a sporadic fashion were excluded from the study. We used the Standardized pressure injury prevention protocol (SPIPP) checklist for our study.

Patients were classified as having sustained a higher grade of injury if their neurological status was ASIA injury severity A or B. For the purpose of comparison and analysis subgroups were created based on neurologic deficit, Grades of PU and requirement of Plastic surgery. Comparison was carried out between and among the different subgroups using Pearson’s and Spearman’s correlation coefficient, T-test and ANOVA [12].

Observations and Analysis

Patient ages ranged from 16 to 55 years. There was only 1 female patient in the studied population, the rest were male. 63% (50) patients had sustained SCI due to Road Traffic accidents while 37% (29) sustained SCI due to fall from a height. There were 20 Quadriplegics and 59 Paraplegics in the studied population. 35 patients had ASIA neurology A/B and 44 had ASIA neurology Grade C/D/E. 18% (14) patients had developed PUs within a week of SCI, 38% (30) before the end of the second week after SCI & 53% (42) by the end of the first month after injury. 47% (37) patients developed PUs later than 1 month after injury.

PUs on admission: All patients at the time of admission to this center had one or more PUs. 1% (1) patient had only one grade 1 PU. 56% (44) patients had grade 2 bed sores only. 32% (25) patients had only grade 3 or 4 bed sores. 14% (11) patients had both grade 1 & 2 PUs. 22% (17) patients had grade1, 2, 3 and 4 PUs. 35% (79) of the PUs on admission were grade 1. 54% (123) were grade 2 and 11% (25) were grade 3 or 4. For Grade 3 or 4 PU, Gluteal and Sacral regions were the most common location - 92% (23). A total of 227 PUs were observed on admission.

PUs after admission: All except 3% (2) patients developed new onset PUs after admission. 47% (37) patients developed only grade 1 PUs. 25% (20) patients developed both grade 1 & 2 PUs. 24% (19) patients had grade 1, 2, 3 and 4 PUs. A total of 380 new onset PUs were observed after admission, of which 66% (249) were grade 1, 29% (112) were grade 2 and 5% (19) were grade 3 or 4. The Ischial regions were most commonly involved with Grade 3 or 4 PUs – 63% (12), followed by the Sacral region – 37% (7).

Treatment modalities: 94% (573) of a total of 607 PUs healed with conservative management (NSAIDs, antibiotics, daily dress¬ing). 30% (24) patients required Reconstructive flap cover surgery. 43% (34) patients needed Vacuum assisted closure techniques for healing of PUs

Correlation Analysis (Table 1): -

Factors that correlated positively with the tendency to have already developed PUs and specifically Grade 3 or 4 PUs by the time of admission; a greater number of PUs overall and the tendency to require Plastic surgical procedures: -

Patients with ASIA neurology of A/B

Patients with quadriplegia

Factors that correlated positively with the tendency to develop PUs after admission: -

Patients with ASIA neurology of A/B

Patients with quadriplegia

Increasing lengths of in-hospital stay

Factors that correlated positively with the tendency to develop a grade 3 or 4 PU after admission: -

History of presence of a grade 3 or 4 PU at the time of admission

Patients with ASIA neurology of A/B There was almost no correlation between the time from injury to onset of first bed sore & presence of Grade 3 or 4 PU on admission. Similarly, the presence of quadriplegia and the tendency to develop a grade 3 or 4 PU after admission did not show significant association

ANOVA Analysis (Table 2):

Significantly greater number of Grade 2 PUs occurred in the Acute phase as compared with Grade 1, Grade 3 and Grade 4 PUs. Significantly more Grade 1 PUs were observed when compared with grade 3 or 4 PUs before admission. After admission in the center significantly greater number of Grade 1 PUs were observed as compared with higher grades. Significantly greater number Grade 2 PUs were observed as compared to Grade 3 or 4 PUs in the rehabilitation phase. T Test Analysis: Significantly greater number of PUs occurred after patients got admitted in the center than before admission. The t-value was 4.33. The p-value was .000013. The result was significant at p < .05

                                        Figure 3: VY Gluteal flap for Sacral PU

Table 1

Table 2

Discussion

In the present study it was observed that all 79 (100%) patients developed at least 1 PU in the Acute post injury phase (Pre-hospital, neurosurgical, emergency care setting) & 77 (97%) of 79 patients developed at least 1 PU after hospitalization at this tertiary care center. This is in contrast to other studies which have reported a PU incidence of up to 69.2%, 47% in the acute phase and 34% - 38% in the acute and rehabilitation phase [13-15]. This discrepancy may have resulted from strictness in documenting even the smallest grade 1 or grade 2 PUs. 37% of the total PUs observed during this study occurred during the acute stage and 63% occurred during the post admission rehabilitation phase. This is in contrast to some studies which reported a greater incidence of PUs in the acute phase than in the rehabilitation phase [15,16]. This may be attributed to the present study spanning 7 years retrospectively. 11% of the PUs observed during the acute phase were grade 3 or 4 (most commonly gluteal and sacral), as compared with 5% during the rehabilitation phase (most commonly ischial followed by sacral). 66% PUs developed in the rehabilitation phase were Grade 1. About 94% of all PUs observed in the present study healed well with conservative methods.

Like in other studies, patients with ASIA A/B neurological impairment were found to have a propensity for developing Higher number of PUs & progression to higher grades of PU, both in the acute and rehabilitation phases. Higher Neurological impairment grades – ASIA A/B and quadriplegia tended to be associated with higher grades of PUs which required NPWT and plastic surgical interventions for complete healing [17-19]. All patients in the present study belonged to the young and middle age group and there was only on female in the studied group, therefore the correlation of PUs with advanced age or gender was not conducted. In this regard other studies have reported an increase in PU occurrence with increasing age and male gender [20-21]. Female gender was found to be positively correlated with developing PUs by one study [22]. In the present study increasing lengths of in-hospital-stay tended to increase the occurrence of PUs. Similar findings have been reported by other studies [23]. It was observed during the present study that patients who had developed Grade 3 or 4 PUs during acute phase, tended to develop grade 3 or 4 PUs again in the rehabilitation period too.

Conclusion

This study showed that all patients of SCI tend to develop at least 1 PU in the early and rehabilitation phases. 94% of PUs in this study healed well with offloading strategies & conservative measures. Higher grades of Neurological impairment (ASIA A/B, Quadriplegia) tended to be associated with Grade 3 or 4 PUs which tended to require NPWT and Plastic surgical flap surgery. ASIA A/B neurology and Quadriplegia were associated with a greater number of PUs overall. SCI patients who developed grade 3 or 4 PUs in the Acute phase, tended to develop grade 3 or 4 PUs in the rehabilitation phase as well. Patients admitted for prolonged periods of time tended to develop more PUs. The results of this study highlighted the importance of careful Observation & meticulous documentation of occurrence, progression and management of PUs and showed that adherence to NPIAP guidelines for PU prevention increases the chance of diagnosing and addressing early PUs, which may otherwise go unnoticed.

References

1. Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised national pressure ulcer advisory panel pressure injury staging system: revised pressure injury staging system. Journal of Wound Ostomy & Continence Nursing, 43(6), 585-597.
2. Krause, J. S., Carter, R. E., Pickelsimer, E. E., & Wilson, D. (2008). A prospective study of health and risk of mortality after spinal cord injury. Archives of physical medicine and rehabilitation, 89(8), 1482-1491.
3. New, P. W., Rawicki, H. B., & Bailey, M. J. (2004). Nontraumatic spinal cord injury rehabilitation: pressure ulcer patterns, prediction, and impact. Archives of physical medicine and rehabilitation, 85(1), 87-93.
4. Salzberg, C. A., Byrne, D. W., Kabir, R., Van Niewerburgh, P., & Cayten, C. G. (1999). Predicting pressure ulcers during initial hospitalization for acute spinal cord injury. Wounds-A Compendium of Clinical Research and Practice, 11(2), 45-57.
5. Lindan, O., Greenway, R. M., & Piazza, J. M. (1965). Pressure distribution on the surface of the human body. I. Evaluation in lying and sitting positions using a" bed of springs and nails". Archives of physical medicine and rehabilitation, 46, 378-385.
6. Richardson, R. R., & Meyer, P. R. (1981). Prevalence and incidence of pressure sores in acute spinal cord injuries. Spinal Cord, 19(4), 235-247.
7. New, P. W., Rawicki, H. B., & Bailey, M. J. (2004). Nontraumatic spinal cord injury rehabilitation: pressure ulcer patterns, prediction, and impact. Archives of physical medicine and rehabilitation, 85(1), 87-93.
8. Ash, D. (2002). An exploration of the occurrence of pressure ulcers in a British spinal injuries unit. Journal of Clinical Nursing, 11(4), 470-478.
9. Verschueren, J. H. M., Post, M. W., de Groot, S., Van Der Woude, L. H. V., Van Asbeck, F. W. A., & Rol, M. (2011). Occurrence and predictors of pressure ulcers during primary in-patient spinal cord injury rehabilitation. Spinal cord, 49(1), 106-112.
10. Leblebici, B., Turhan, N., Adam, M., & Akman, M. N. (2007). Clinical and epidemiologic evaluation of pressure ulcers in patients at a university hospital in Turkey. Journal of Wound Ostomy & Continence Nursing, 34(4), 407-411.
11. Daniel, R. K., & Faibisoff, B. (1982). Muscle coverage of pressure points—the role of myocutaneous flaps. Annals of plastic surgery, 8(6), 446-452.
12. Pittman, J., Black, J. M., de Jesus, A., & Padula, W. V. (2024). The standardized pressure injury prevention protocol (SPIPP) checklist 2.0: content validation. Journal of advanced nursing, 80(6), 2584-2591.
13. DeVivo, M. J. (2012). Epidemiology of traumatic spinal cord injury: trends and future implications. Spinal cord, 50(5), 365-372.
14. National Spinal Cord Injury Statistical Center. (2005). Annual report for the model spinal cord injury care systems. Birmingham, AL: National Spinal Cord Injury Statistical Center.
15. New, P. W., Rawicki, H. B., & Bailey, M. J. (2004). Nontraumatic spinal cord injury rehabilitation: pressure ulcer patterns, prediction, and impact. Archives of physical medicine and rehabilitation, 85(1), 87-93.
16. Hammond, M. C., Bozzacco, V. A., Stiens, S. A., Buhrer, R., & Lyman, P. (1994). Pressure ulcer incidence on a spinal cord injury unit. Advances in Skin & Wound Care, 7(6), 57-60.
17. Brienza, D., Krishnan, S., Karg, P., Sowa, G., & Allegretti,A. L. (2018). Predictors of pressure ulcer incidence following traumatic spinal cord injury: a secondary analysis of a prospective longitudinal study. Spinal cord, 56(1), 28-34.
18. Chen, Y., DeVivo, M. J., & Jackson, A. B. (2005). Pressure ulcer prevalence in people with spinal cord injury: age-period-duration effects. Archives of physical medicine and rehabilitation, 86(6), 1208-1213.
19. Scheel-Sailer, A., Wyss, A., Boldt, C., Post, M. W., & Lay,V. (2013). Prevalence, location, grade of pressure ulcers andassociation with specific patient characteristics in adult spinal cord injury patients during the hospital stay: a prospective cohort study. Spinal cord, 51(11), 828-833.
20. Hitzig, S. L., Tonack, M., Campbell, K. A., McGillivray, C. F., Boschen, K. A., Richards, K., & Craven, B. C. (2008). Secondary health complications in an aging Canadian spinal cord injury sample. American journal of physical medicine & rehabilitation, 87(7), 545-555.
21. Okuwa, M., Sanada, H., Sugama, J., Inagaki, M., Konya, C., Kitagawa, A., & Tabata, K. (2006). A prospective cohort study of lower-extremity pressure ulcer risk among bedfast older adults. Advances in skin & wound care, 19(7), 391-397.
22. Perneger, T. V., Héliot, C., Raë, A. C., Borst, F., & Gaspoz, J. M. (1998). Hospital-acquired pressure ulcers: risk factors and use of preventive devices. Archives of internal medicine, 158(17), 1940-1945.
23. Eslami, V., Saadat, S., Habibi Arejan, R., Vaccaro, A. R., Ghodsi, S. M., & Rahimi-Movaghar, V. (2012). Factors associated with the development of pressure ulcers after spinal cord injury. Spinal Cord, 50(12), 899-903.