Pressure ulcers in spinal cord injury: an unusual site and etiology.

Abstract

Case series of pressure ulcers in patients with spinal cord injury after inappropriate and prolonged application of graduated compression stockings are presented. Three adult patients with spinal cord injury were fitted with graduated compression stockings in the acute phase to prevent thromboembolism. Acute hospital staff did not monitor the skin for potential pressure ulcer because of the graduated compression stockings. Grade II pressure ulcers developed on the toes in all three cases. All pressure ulcers were managed conservatively and healed without complication. The manufacturers of graduated compression stockings did not include information about the need to monitor patients with sensory impairment for pressure ulcers. It is suggested that the manufacturers of graduated compression stockings include information about the need to monitor patients with sensory impairment for skin breakdown. When graduated compression stockings are applied to patients with sensory impairment, including spinal cord injury, staff needs to be vigilant for pressure ulcers occurring at the extremes of the graduated compression stockings, in addition to the more common areas where pressure ulcers occur.

Full text

Page 1

Authors:
Farooq A. Rathore, MBBS
P. W. New, MClinEpi, FAFRM (RACP)
Akhtar Waheed, MBBS, MCPS, FCPS
Affiliations:
From the Spinal Rehabilitation Unit
(FAR, AW), AF Institute of
Rehabilitation Medicine, Rawalpindi,
Pakistan; Spinal Rehabilitation Unit
(PWN), Caulfield General Medical
Centre, Bayside Health, Melbourne,
Australia; and Departments of
Medicine (PWN) and Epidemiology
and Preventive Medicine (PWN),
Monash University, Melbourne,
Victoria, Australia.
Correspondence:
All correspondence and requests for
reprints should be addressed to
Farooq A. Rathore, MBBS, AF
Institute of Rehabilitation Medicine,
Abid Majeed Rd., Rawalpindi 46000,
Pakistan.
Disclosures:
None.
0894-9115/09/8803-0001/0
American Journal of Physical
Medicine & Rehabilitation
Copyright © 2009 by Lippincott
Williams & Wilkins
DOI: 10.1097/PHM.0b013e318198b6d7
Pressure Ulcers in Spinal Cord
Injury
An Unusual Site and Etiology
ABSTRACT
Rathore FA, New PW, Waheed A: Pressure ulcers in spinal cord injury: An
unusual site and etiology. Am J Phys Med Rehabil 2009;88:000–000.
Case series of pressure ulcers in patients with spinal cord injury after inappro-
priate and prolonged application of graduated compression stockings are pre-
sented. Three adult patients with spinal cord injury were fitted with graduated
compression stockings in the acute phase to prevent thromboembolism. Acute
hospital staff did not monitor the skin for potential pressure ulcer because of the
graduated compression stockings. Grade II pressure ulcers developed on the
toes in all three cases. All pressure ulcers were managed conservatively and
healed without complication. The manufacturers of graduated compression stock-
ings did not include information about the need to monitor patients with sensory
impairment for pressure ulcers. It is suggested that the manufacturers of gradu-
ated compression stockings include information about the need to monitor
patients with sensory impairment for skin breakdown. When graduated compres-
sion stockings are applied to patients with sensory impairment, including spinal
cord injury, staff needs to be vigilant for pressure ulcers occurring at the extremes
of the graduated compression stockings, in addition to the more common areas
where pressure ulcers occur.
Key Words:
Stockings
Pressure Ulcers, Spinal Cord Injury, Thromboprophylaxis, Compression
Pressure ulcers are a frequent complication of spinal cord injury (SCI).1,2
There are numerous risk factors for developing a pressure ulcer.2–4Pressure
ulcers may develop anytime after SCI5and are among the costliest complica-
tions.6They are responsible for an increased length of stay in hospital7and are
an important cause of rehospitalization.5This is despite the availability of
evidenced-based prevention guidelines.8
Patients with SCI are also at a high risk of developing thromboembolic
disorders: deep vein thrombosis and pulmonary embolism.9Graduated com-
pression stockings (GCS) fitted to the lower limbs combined with other forms
of thromboprophylaxis are one of the effective means of reducing the risk of
thrombosis.10,11We present three case reports of patients with SCI who devel-
oped pressure ulcers secondary to prolonged and inappropriate application of
GCS.
March 2009 Pressure Ulcers on the Foot in SCI
1
CASE REPORT
Pressure Ulcers

Page 2

CASE REPORTS
Case 1
A 20-yr-old man was involved in a car accident
resulting in a T5 ASIA A SCI. He had surgery for a
T5 fracture dislocation within 24 hrs at an acute
hospital. A week later, he was transferred to a
spinal rehabilitation unit. On admission, his neu-
rologic status was unchanged and there were no
pressure ulcers in any of the usual pressure ulcer
prone areas. He had calf-length GCS applied to
both legs just after the surgery, which were not
removed or changed until he was admitted to the
rehabilitation unit. When the stockings were re-
moved, pressure ulcers in the form of blisters were
seen on the lateral aspect of both little toes and
medial aspect of left big toe (Fig. 1). The ulcers
were graded as stage 2 on national pressure advi-
sory panel classification.12The pressure ulcers
were managed conservatively, healing over 4 wks
without infection or other complication.
Case 2
A 75-yr-old man sustained a traumatic C5 ASIA
B SCI in a bus accident. He was evacuated by
ambulance to a major hospital and was transferred
to rehabilitation after 2 wks. On admission, there
were no pressure ulcers in any of the usual pres-
sure ulcer–prone areas. Skin lesions consistent
with deep bruising were present on the lateral
aspects of both small toes and medial aspect of
right big toe (Fig. 2). The lesions were consistent
with grade 2 pressure ulcers. The patient reported
that thigh length GCS were applied by the nursing
staff in the previous hospital. Three days after ap-
plication of pressure garments discoloration of his
skin was noticed and the GCS removed. The pres-
sure ulcers responded well to conservative manage-
ment without incident.
Case 3
A 78-yr-old man developed progressive leg
pain over a few hours and presented to the hospital.
He developed leg weakness and incontinence of
bladder and bowel. A magnetic resonance imaging
scan was performed that was indicative of a spinal
cord infarction of the lower thoracic cord. He had
knee-length GCS applied bilaterally. He was trans-
ferred to a rehabilitation unit 7 days later. On
admission, he was noted to have bruising of his
right big toe. He reported that the skin around his
toes had not been routinely inspected by staff at the
acute hospital, as far as he could determine.
DISCUSSION
Pressure ulcers continue to occur in SCI,
despite a better understanding of their patho-
physiology, risk factors, and availability of pres-
sure relief surfaces. In developing countries like
FIGURE 1
Grade II pressure ulcer on lateral right
little toe.
FIGURE 2
Deep bruising (grade II pressure ulcer) on
medial aspect of right big toe.
2
Rathore et al.
Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 3

Page 3

Pakistan, even today they can be fatal for a pa-
tient with SCI.13
These cases highlight the balance between
risks and benefits from any medical intervention.
In the experience of the Australian-based author
(P. W. New), GCS or pneumatic compression de-
vices are routinely used in all patients with SCI in
the acute phase. In the experience of the Pakistan-
based authors (F. A. Rathore, A. Waheed) only few
patients with SCI are offered thromboprophylaxis
in the acute phase. It would seem that the risk of
pressure ulcers occurring due to ill-fitting GCS is
quite small. It has been reported that South-East
Asians undergoing orthopedic procedures14and af-
ter SCI15are at lower risk of thromoembolism, com-
pared with whites. Given the potential serious conse-
quences of thromboembolism, and the relative
cheapness of GCS compared with other prophylactic
treatments,wedonotadvocatethattheuseofGCSin
patients with SCI needs to be withheld.
The information supplied by the manufactur-
ers of the commonly used GCS at the acute hospi-
tals in our countries where these cases occurred
(Pakistan - Kendall T.E.D antiembolism stockings,
Tyco Health care group, Mansfield, TX; E Sallis
antiembolic stockings, E Sallis Pvt. Ltd., Basford,
Nottingham, United Kingdom; Brevet tx—antiem-
bolism stockings Australia-Opal SAM antiembolic
stockings, Orthopaedic Alliances Pvt. Ltd., Bruns-
wick, Victoria, Australia; and thrombexin 18, Medi,
GmbH & Co. KG, Bayreuth, Germany) do mention
the need to ensure correct application, but do not
include any information regarding patients with
sensory impairment needing special precautions.
Because of their sensory impairment, patients with
SCI are at risk of a pressure ulcer because of
incorrectly applied GCS. This can occur, as did in
our cases, if the distal end encroaches over the
toes, or if the proximal end rolls down. The man-
ufacturers of GCS should include a warning in
their instructions regarding the need for monitor-
ing for skin damage in patients with sensory im-
pairment in the lower limbs.
In the cases presented, all pressure ulcers oc-
curred in acute hospitals because of inadequate
fitting and monitoring of GCS. This illustrates a
lack of knowledge regarding pressure ulcer preven-
tion among staff in acute hospitals where these
patients were initially managed. These cases high-
light the need for regular skin inspections in all
patients with SCI, in acute and rehabilitation hos-
pitals. All at-risk areas, including the lower limb
areas at the extreme ends of GCS, if applied, must be
reviewed. The importance of this should to be repeat-
edly emphasized to all health-care professionals.
There are a few issues that apply to Pakistan in
the context of these cases reports. Lack of knowl-
edge regarding pressure ulcer prevention on the
part of the doctors and delay in identification of
early signs of skin breakdown have been noted as
contributing factors in pressure ulcer formation in
SCI.16Regular skin inspection is not routinely per-
formed in most of the surgical units around the
country, and no spinal or neurosurgical unit car-
ries out pressure ulcer risk assessment and docu-
mentation at admission with a validated risk as-
sessment tool. In addition, there are no formally
trained rehabilitation or SCI nurses in Pakistan;
therefore, monitoring for pressure ulcer if any is
carried out by the doctors themselves. It is sug-
gested that spinal rehabilitation units using a mul-
tidisciplinary team be established in Pakistan17and
pressure ulcer prevention and monitoring be
taught to the nurses as part of their training.
CONCLUSIONS
Pressure ulcer prevention in SCI is a multidis-
ciplinary task requiring knowledge and vigilance.
GCS are an economical and easy-to-use method of
providing thromboprophylaxis to a patient with
SCI. Prolonged application without adequate mon-
itoring may result in the development of pressure
ulcers at sites not usually affected. It is important
that the GCSs are the correct size and inspection
for pressure ulcers is carried out routinely.
REFERENCES
1. Ho CH, Bogie K: The prevention and treatment of
pressure ulcers. Phys Med Rehabil Clin N Am 2007;
18:235–53
2. Haisma JA, Van der Woude LH, Stam HJ, et al:
Complications following spinal cord injury: Occur-
rence and risk factors in a longitudinal study during
and after inpatient rehabilitation. J Rehabil Med
2007;39:393–8
3. Frankel H, Sperry J, Kaplan L: Risk factors for pres-
sure ulcer development in a best practice surgical
intensive care unit. Am Surg 2007;73:1215–17
4. Fogerty MD, Abumrad NN, Nanney L, et al: Risk
factors for pressure ulcers in acute care hospitals.
Wound Repair Regen 2008;16:11–18
5. Cardenas DD, Hoffman JM, Kirshblum S, et al: Eti-
ology and incidence of rehospitalization after trau-
matic spinal cord injury: A multicenter analysis.
Arch Phys Med Rehabil 2004;85:1757–63
6. Dini V, Bertone M, Romanelli M: Prevention and
management of pressure ulcers. Dermatol Ther
2006;19:356–64
7. New PW, Rawicki HB, Bailey MJ: Nontraumatic spi-
nal cord injury rehabilitation: Pressure ulcer pat-
terns, prediction, and impact. Arch Phys Med Reha-
bil 2004;85:87–93
8. Consortium for Spinal Cord Medicine Clinical Prac-
tice Guidelines: Pressure ulcer prevention and treat-
ment following spinal cord injury: A clinical practice
guideline for health-care professionals. J Spinal
Cord Med 2001;24(suppl 1):S40–S101
March 2009Pressure Ulcers on the Foot in SCI
3

Page 4

9. Blann AD, Lip GYH: Venous thromboembolism. Br
Med J 2006;332:215–19
10. Geerts WH, Pineo GF, Heit JA, et al: Prevention of
venous thromboembolism: The Seventh ACCP Con-
ference on Antithrombotic and Thrombolytic Ther-
apy. Chest 2004;126(3 suppl):338S–400S.
11. Epstein NE: A review of the risks and benefits of
differing prophylaxis regimens for the treatment of
deep venous thrombosis and pulmonary embolism
in neurosurgery. Surg Neurol 2005;64:295–301
12. Panel for Prediction and Prevention of Pressure
Ulcers in Adults. Prediction and Prevention. Rock-
ville, MD, Agency for Health Care Policy and Re-
search, Public Health Service, U.S. Department of
Health and Human Services, 1992, Clinical Practice
Guideline No. 3, AHCPR publication No. 92-0047
13. Rathore FA, Farooq F, Butt AW, et al: An update on
spinal cord injury patients of Oct 2005 earthquake in
Pakistan [Letter]. Spinal Cord 2008;46:461–2
14. Jain V, Dhaon BK, Jaiswal A, et al: Deep vein throm-
bosis after total hip and knee arthroplasty in Indian
patients. Postgrad Med J 2004;80:729–31
15. Rathore FA, Hanif S, Rashid P, et al: The incidence of
deep vein thrombosis in a cohort of patients with
spinal cord injury following the Pakistan earthquake
of October 2005. Spinal Cord. 2008;46:523–6
16. Rathore MF, Rashid P, Butt AW, et al: Epidemiology
of spinal cord injuries in the 2005 Pakistan earth-
quake. Spinal Cord 2007;45:658–63
17. Rathore FA, Hanif S, Farooq F, et al: Traumatic
spinal cord injuries at a tertiary care rehabilitation
institute in Pakistan. J Pak Med Assoc 2008;58:53–7
4
Rathore et al.
Am. J. Phys. Med. Rehabil. ● Vol. 88, No. 3