Pressure ulcers continue to impact the lives of spinal cord injury patients severely. Pressure ulcers must be accurately staged according to National Pressure Ulcer Advisory recommendations before treatment design. The first priority in treatment of pressure ulcers is offloading. Intact skin ulcers may be treated with noncontact nonthermal low-frequency ultrasound. Superficial pressure ulcers may be treated with a combination of collagenase and foam dressings. Deeper pressure ulcers warrant negative-pressure wound therapy dressings along with biologic adjuncts to fill in wound depth. Discovery and treatment of osteomyelitis is a high priority when initially evaluating pressure ulcers. Surgical intervention must always be considered.
Key points
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Pressure ulcers must be adequately assessed to design proper treatment.
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Wound dressings should be designed based on depth and suspected wound biofilm.
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Pressure ulcers must be treated by offloading as a priority.
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Pressure ulcers must be adequately debrided of devitalized tissue.
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Negative-pressure wound therapy is the dressing of choice for most stage III and IV pressure ulcers.
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Surgical intervention must be considered when addressing a pressure ulcer.
Pressure ulcers are a major source of morbidity and mortality for spinal cord injury patients worldwide. Prevalence of pressure ulcers in persons with spinal cord injury has been shown to be up to 30% in patients with chronic spinal cord injury and up to 49% in patients in the acute rehabilitation phase. A well-known complication of spinal cord injury is urinary tract infections. In Japan, pressure ulcers rival urinary tract infections in doubling the hospital length of stay and tripling medical expenses for patients with spinal cord injury. In Canada the average monthly healthcare costs of a person with spinal cord injury living with a pressure ulcer in the community approach $5000. Not only do pressure ulcers alter the lives of patients by increasing hospital length of stay and healthcare costs, but pressure ulcers can have a major impact on patients’ lives in other ways. Depression is a known risk factor for developing a pressure ulcer, and hospitalization for a pressure ulcer in the patient with spinal cord injury and depression can lead to a suicide attempt.
Classification of pressure ulcers is relatively straightforward and has been well-outlined by the National Pressure Ulcer Advisory Panel. The stages and categories discussed next can be found on the National Pressure Ulcer Advisory Panel Web site.
Pressure ulcer stages and categories
Category/Stage I: Nonblanchable Erythema
This stage includes intact skin with nonblanchable redness of a localized area usually over a bony prominence ( Table 1 ). Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler compared with adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. It may indicate “at risk” persons.
| Pressure Ulcer Category | Recommended Dressing | Trade Names |
|---|---|---|
| Stage I pressure ulcer | Offloading, noncontact/nonthermal ultrasound | Various specialty beds and mattresses, MIST |
| Stage II pressure ulcer | Collagenase, foam dressings, adherent dressings | Santyl, Polymem, Mepilex, Mefix, Medipore |
| Stage III pressure ulcer | Negative-pressure wound therapy, collagen dressings, skin substitutes | VAC, SNAP, Prisma, Fibracol, Dermagraft, Epifix, Amniofix, Matristem |
| Stage IV pressure ulcer | Negative-pressure wound therapy, collagen dressings, skin substitutes | VAC, SNAP, Prisma, Fibracol, Dermagraft, Epifix, Amniofix, Matristem |
| Unstageable pressure ulcer | Sharp debridement, cadexomer iodine dressings, silver dressings | Iodoflex, Silvasorb, Acticoat |
| Suspected deep tissue Injury | Offloading, noncontact/nonthermal ultrasound | Various specialty beds and mattresses, MIST |
Category/Stage II: Partial Thickness
This partial-thickness loss of dermis presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open or ruptured serum-filled or serosanginous-filled blister. It presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates deep-tissue injury). This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation.
Category/Stage III: Full-Thickness Skin Loss
This is full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling. The depth of a category/stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and category/stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category/stage III pressure ulcers. Bone or tendon is not visible or directly palpable.
Category/Stage IV: Full-Thickness Tissue Loss
This includes full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. It often includes undermining and tunneling. The depth of a category/stage IV pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone or muscle is visible or directly palpable.
Pressure ulcer stages and categories
Category/Stage I: Nonblanchable Erythema
This stage includes intact skin with nonblanchable redness of a localized area usually over a bony prominence ( Table 1 ). Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler compared with adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. It may indicate “at risk” persons.
| Pressure Ulcer Category | Recommended Dressing | Trade Names |
|---|---|---|
| Stage I pressure ulcer | Offloading, noncontact/nonthermal ultrasound | Various specialty beds and mattresses, MIST |
| Stage II pressure ulcer | Collagenase, foam dressings, adherent dressings | Santyl, Polymem, Mepilex, Mefix, Medipore |
| Stage III pressure ulcer | Negative-pressure wound therapy, collagen dressings, skin substitutes | VAC, SNAP, Prisma, Fibracol, Dermagraft, Epifix, Amniofix, Matristem |
| Stage IV pressure ulcer | Negative-pressure wound therapy, collagen dressings, skin substitutes | VAC, SNAP, Prisma, Fibracol, Dermagraft, Epifix, Amniofix, Matristem |
| Unstageable pressure ulcer | Sharp debridement, cadexomer iodine dressings, silver dressings | Iodoflex, Silvasorb, Acticoat |
| Suspected deep tissue Injury | Offloading, noncontact/nonthermal ultrasound | Various specialty beds and mattresses, MIST |
Category/Stage II: Partial Thickness
This partial-thickness loss of dermis presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open or ruptured serum-filled or serosanginous-filled blister. It presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates deep-tissue injury). This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation.
Category/Stage III: Full-Thickness Skin Loss
This is full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling. The depth of a category/stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and category/stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category/stage III pressure ulcers. Bone or tendon is not visible or directly palpable.
Category/Stage IV: Full-Thickness Tissue Loss
This includes full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. It often includes undermining and tunneling. The depth of a category/stage IV pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone or muscle is visible or directly palpable.
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