Toolkit

Pressure Injury Toolkit For Spinal Cord Injury and Spina Bifida

Beyond the wound - Bringing best practice to the bedside

Surgery

Pre and post-operative considerations and planning ^{20, 11}

Surgery can play an important role in the management of pressure injuries (for example stage 3 or 4, DTI) that are non-responsive to other management strategies. There are a range of surgical interventions possible, such as surgical debridement, direct wound closure, skin grafting, and skin, fasciocutaneous or myocutaneous flap repairs. Advantages may include definitive wound debridement with skin and soft tissue coverage, improved vascularity, healing from underlying osteomyelitis, and so on -allowing the person to regain function and independence more efficiently.

Surgical repair of a pressure injury is different for each individual. A comprehensive multidisciplinary evaluation by the tertiary Spinal Plastics Service in collaboration with the person considering his or her preferences is necessary prior to any decision for surgical intervention.

Complications can occur and an extended period of hospitalisation followed by a graduated and significantly limited sitting time is required following the surgery.
Post-surgical skin may be more vulnerable to re-injury. Equipment, weight shifting strategies, transfers, nutrition, general health and knowledge of PI prevention will need to be optimised and any lifestyle factors addressed to prevent a new PI or recurrence.
Complex surgical management of a PI in a person with SCI or SB , involving a flap repair or other major reconstructive surgery, such as a flap in combination with proximal femoral osteotomy (Girdlestone procedure) or end-stage lower extremity disarticulation and total thigh flap, should only be done in a specialist centre (see Referral).

The success of surgery relies on ^{11, 20}:

The wound being clean and having a granulating wound bed; as well as the person being:

Able to keep the surgical site free from pressure for the post-operative period.
Motivated and knowledgeable about pressure injury prevention and making changes to address both the cause of the PI and contributing factors.
Supported with adequate psychosocial support, resources and knowledge to sustain the changes they have made to prevent future PIs.

In general, flap surgery involves¹¹:

Infected tissue and scar tissue debridement (usually prior to the flap surgery) to produce a clean wound. In some cases debridement may result in a larger wound area due to removal of infected or necrotic tissue.
During flap surgery, infected bone and irregular bone that would cause a point of pressure are removed.
A well-vascularised flap is freed from an adjacent part of the body and moved or rotated and then reconstructed over the defect. The flap covers and protects the affected bony prominence with healthy tissue.

Pre-operative planning

The cause and contributing factors must be addressed prior to surgery. The tertiary SCI or SB service will assess and provide pre-operative recommendations specific to each individual person with a PI.

Assess, treat and optimise:	The following factors will be considered^{1, 2}:
Local wound infection Wound bed and size Nutritional status Respiratory function Spasm and contracture Pain Bladder and bowel management with no risk of wound contamination Urinary tract infection Psychological disorder Social and psychological support Pressure, friction and shear risks Equipment to provide optimal pressure care both post discharge and in the long term Daily routine to support skin integrity Assistance that will be required at home on discharge Counselling, psychosocial and peer support	Ability of the person to sustain a position on bed rest where the surgical site is free of pressure for the post-surgical period (usually a minimum of 21 days not including the gradual return to sitting period). Comorbid medical conditions: vascular disease, renal impairment, sleep disordered breathing, diabetes. Previous surgery for PI Smoking cessation Drug and alcohol cessation Osteomyelitis Heterotopic ossification Cognitive capacity including problem solving, planning, memory, coping skills, attention and insight.

Assess, treat and optimise:

The following factors will be considered^{1, 2}:

Local wound infection
Wound bed and size
Nutritional status
Respiratory function
Spasm and contracture
Pain
Bladder and bowel management with no risk of wound contamination
Urinary tract infection
Psychological disorder
Social and psychological support
Pressure, friction and shear risks
Equipment to provide optimal pressure care both post discharge and in the long term
Daily routine to support skin integrity
Assistance that will be required at home on discharge
Counselling, psychosocial and peer support

Ability of the person to sustain a position on bed rest where the surgical site is free of pressure for the post-surgical period (usually a minimum of 21 days not including the gradual return to sitting period).
Comorbid medical conditions: vascular disease, renal impairment, sleep disordered breathing, diabetes.
Previous surgery for PI
Smoking cessation
Drug and alcohol cessation
Osteomyelitis
Heterotopic ossification
Cognitive capacity including problem solving, planning, memory, coping skills, attention and insight.

Post-operative care usually involves the following:

Period of inpatient care usually in a spinal cord injury unit on complete bed rest.
Positioning to keep direct pressure off the surgical site.
Use of optimal support surfaces. For example, an alternating air mattress replacement is usually required.
Frequent repositioning to reduce risk of skin breakdown of other sites – use of a slide-sheet and correct manual handling techniques to minimise shear and friction.
Specialised seating assessment and regular evaluation.
Progressive sitting, once the surgical site has healed, over 4-8 weeks using a gradual return to sitting protocol.
Evaluation and optimisation of wheelchair seating and other support surfaces such as the commode and mattress (only those support surfaces that have been assessed and optimised will be introduced into the protocol).
Gradual introduction of new potential mechanical stressors and evaluation of their effect on the skin (including transfers, commode use, downgrading of the mattress).
Provision of pressure management and skin checking education tailored to the individual to reduce future PI risk.
Provision of psychological support, counselling and monitoring of mood and quality of life.
Family and/or social support is important during this period.

Spina Bifida

Amputation of lower limbs has a significant impact on wheelchair seating and can lead to further PI development, particularly over the ischial tuberosities (ITs), as illustrated by Emily’s story page 20 of SCISB Model of care i.e.

The post-operative protocol is different for every individual and should be closely monitored.

Spinal Tip

Start discharge planning prior to admission to hospital for surgical management where possible.
Consult the occupational therapist and seating therapist regarding the equipment (for example, the cushion, type of wheelchair, mattress, and commode) required in the post-operative period and longer term to protect the skin.
Ensure that there is an arrangement for adequate personal care hours for position changes, bathing, nutrition and continuing a safe gradual return to sitting plan at home.
Ensure that people who have to take time off work have adequate financial security to do so.
Time spent during initial planning is critical to a successful surgical outcome.

Children with SCI or SB

Further your knowledge

Online Resource

Image of an example of flap advancement surgery for an ischial tuberosity PI.

Case Study

NSW State Spinal Cord Injury Service Model of Care for Prevention and Integrated Management of Pressure Injuries in People with Spinal Cord Injury and Spina Bifida (2014). p. 15