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Surgical and Other Miscellaneous Topical and Physical Treatments

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The introductory information on incidence, prevalence and impact of pressure ulcers solidify the importance of understanding the spectrum of prevention and management of pressure ulcers, especially in people with SCI given their neurologically compromised sensation, mobility and cardiovascular functions. Previous sections of this chapter have discussed assessment of risk factors and assessment. The most important factor in the management of all stages of ulcers (i.e. SDTI, stage I, II, III, IV) is a comprehensive assessment of risk factors and co-morbidities to choose the most effective treatment methods. Regular reassessment is also necessary, especially in more severe ulcers (i.e. stage III and IV) that are often persistent and/or recur. There are many non-surgical methods of management that facilitate healing of all pressure ulcers but stage IV ulcers almost always require surgery. Before surgery is elected, removal of unhealthy tissue using surgical (and non-surgical) methods is a standard procedure that can also expedite the healing of persistent stage III and IV ulcers. The studies reviewed in this section provide evidence that surgery can reduce rehabilitation costs and time by preventing protein loss from the wound, development of sepsis or osteomyelitis and development of additional skin conditions, such as Fournier’s gangrene (Backhaus et al. 2011) and necrotizing fasciitis (Citak et al. 2011), secondary to the pressure ulcer. Some studies also provide data to support surgical choices that improve quality of life of people with severe ulcers by decreasing limitations of daily functioning and improving the hygiene and appearance of the skin. With the many surgical reconstruction options available for wound repair, this section attempts to summarize the potential benefits of surgical repair for pressure ulcers in people with SCI.

Table: Surgical and Other Miscellaneous Topical and Physical Treatments

Discussion

Consistent across the studies (all uncontrolled and observational; level 5 evidence) included in this review, was the confirmation of the most severe pressure ulcers occurring in the buttock and hip areas in individuals with SCI due to being primary wheelchair users. The most common types of severe pressure ulcers in people with SCI were confirmed, in descending order: ischial, sacral and trochanteric (Grassetti et al. 2013, Biglari et al. 2013, Mehta 2012, Chen et al. 2011, Kierney et al.1998, Relander&Palmer 1988).

Before surgical reconstruction is elected as a treatment option, a long-standing preparatory procedure is to excise diseased tissue in and around the wound to reduce the risk of wound progression and infection (Conway & Griffith, 1956). Although the most common method of debridement is also surgical, non-surgical debridement methods have also been used to treat pressure sores in people with SCI and are discussed in section 3.9 (Non-Surgical Management and Debridement for Healing of Pressure Ulcers Post SCI).

Erba et al. (2010) confirmed the pyramidal shape of severe pressure ulcers (i.e. grade III and IV) by analyzing silicone imprints of the ulcer cavity and provided evidence of more pronounced deep muscle tissue pressure sensitivity relative to resilience to pressure in the superficial layers of ectodermal tissue. Therefore, the surface opening of the wound is quite small relative to base of the pyramidal cavity. Even with active pressure relief strategies counteracted by the almost sole reliance on the wheelchair for mobility, grade IV ulcers are at constant risk for persistence and progression. It is not uncommon that grade IV ulcers in the buttock and hip regions are large and require careful considerations of surgical flaps to provide enough coverage and vascularization for effective closure. Diaz et al. (2013) provide a listing of the types of flaps best suited for different types of pressure ulcers and although the authors providing evidence in this current review, echo the matching of flap type to defect type, some flaps appear to be more commonly chosen for defect correction in people with SCI. Specifically, the subset of flaps reported in this current review include thigh (posterior, lateral, medial) and buttocks (gluteus maximus, tensor fascia latae), fascio-cutaneous, myofascio-cutaneous, bi-planer, and flaps perforated with inferior and superior gluteal artery and profunda femoris artery. An informed comparison of all the types of flaps used to close the various types of pressure ulcers (e.g., severity grade and location) is beyond the scope of this chapter. Instead, a table detailing the flap type and pressure ulcer characteristics is provided for those who wish to look into further comparisons.

Table: Studies Assessing Pressure Ulcer Surgical Flaps

This table is intended to help identify the flap types used for the most common severe pressure ulcers (i.e., grade III and IV, ischial, sacral and trochanteric) in people with SCI and echos a subset of a much longer list of flap types presented by Diaz et al. (2013). Specifically, the subset of flaps reported in this current review include thigh (posterior, lateral, medial), buttocks (gluteus maximus, tensor fascia latae), fascio-cutaneous, myofascio-cutaneous, bi-planer, and flaps perforated with inferior and superior gluteal artery and profunda femoris artery.

In all studies considered here, reported recurrence rates continue to decline as surgical reconstruction methods evolved over the last 75 years (Davies 1938). The use of flaps with varying degrees of vascularization and tissue layers chosen to match the type of wound requiring repair has been of benefit to recurrence rates. Relander and Palmer (1988) reported no difference in recurrence rate between pressure ulcers treated with cutaneous and musculo-cutaneous flaps despite better initial healing response to musculo-cutaneous flaps (e.g., muscle tissue eventually undergoes atrophy). However the high recurrence rate for these flap types reported 25 years ago (48%; Relander & Palmer 1988) has fortunately continued to decrease (22%, Kierney et al.1998; 17%, Lin et al. 2010), likely due to the improvement in collaboration between caregivers and also in patient education (Kierney et al.1998). Use of combination flaps (Ahluwalia et al. 2010) or flaps novel in design (Borgognone et al. 2010) have reported even further decreases in recurrence rates (e.g., 7% and 8%, respectively). However, use of the biceps femoris flap on its own may be prone to a high complication rate (38.4% for grade IV ischial sores; Bertheuil et al. 2013) which may be reduced if used in conjunction with a posterior medial thigh fascio-cutaneous flap (15% for grade III and IV Ischial sores; Ahluwalia et al. 2010). The reported recurrence rates differed significantly and were likely impacted by the follow-up period at the time of reporting. For example, Tavakoli et al. (1999) reported that 33% and 47.8% of patients had recurrence of ulcers at an average follow-up period of 20 and 62 months, respectively. Patients lost to follow-up (including for reason of death) over the longer time period also impacted the related rates of patients with recurring ulcers (e.g., N=27 at 20 month follow-up versus N=19 at 62 months follow-up).

Two level 5 studies (Chen et al. 2011; NSCI/N=141/160 and Grassetti et al. 2013; NSCI/N=107/143) similar in study size, and pressure ulcer grade and location (IV; ischael, sacral, trochanteric) suggest an average length of hospitalization of approximately 45 and 16 days, respectively. The study by Chen et al. (2011) was primarily a description and observation of a novel traction closure method that should not be compared with traditional surgical closure. However, the study by Grassetti et al. (2013) can be favourably compared to length of stay data for general pressure ulcer reconstruction surgery patients reported at 20 days (Larson et al. 2012; Foster et al. 1997) and even up to 79 days (Marriott & Rubayi 2008; Isik et al. 1997; Srivastava et al. 2009; Relander & Palmer 1988). Considering the significant costs associated with pressure ulcer healing in the hospital (Zoutman et al.1998) and in the community (Chan et al. 2013) a reduction in healing time is also of benefit to health care systems. Surgical reconstruction of pressure ulcers in people with SCI can also improve Barthel Index scores (Srivastava et al. 2009), feelings of well-being (76.6%) and satisfaction with rehabilitation (83.3%) as reported after patients underwent surgical repair of severe pressure ulcers (Singh et al. 2010).

Based on level 5 evidence, caregiver collaboration (Kierney et al. 1998) and flap type selection (Ahluwalia et al. 2010; Borgognone et al. 2010; Bertheuil et al. 2013) when considering surgical reconstruction of severe pressure ulcers, facilitates healing (Grassetti et al.2013) without undue risk of complications (Ahluwalia et al. 2010; Borgognone et al. 2010) and improves the well-being and satisfaction with the rehabilitation experience (Singh et al. 2010) of people with SCI. However, a sufficiently powered, controlled study is needed to investigate the degree of benefit of severe pressure ulcer reconstruction for individuals living with SCI.

Conclusion

There is level 5 evidence that supports various surgical repair methods for persistent, severe thigh and buttock pressure ulcers secondary to SCI, as a beneficial treatment option.

  • People with spinal cord injury with persistent grade III and IV pressure ulcers in the thigh and buttock region may benefit from surgical reconstruction