Living With A Spinal Cord Injury: Pressure Sores

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Pressure Sores

Pressure sores (bed sores) are an injury to the skin and underlying tissue. They are a frequent and sometimes serious complication of a spinal cord injury (SCI). They can range from mild reddening of the skin to severe complications, such as infection of the bone (osteomyelitis) or blood (sepsis). They can be difficult to treat and slow to heal.

In people with SCIs, the nerves that normally signal discomfort and alert you to relieve pressure by changing position may no longer work. It is important for you to pay attention to possible pressure sores and change your position frequently when you are sitting or lying down.

Pressure sores are usually caused by unrelieved pressure. They often develop on skin that covers bony areas (such as the hips, heels, or tailbone). Constant pressure on the skin reduces blood supply to the skin and underlying tissues. Oxygen and nutrients carried by the blood cannot reach the cells in the tissue, eventually causing cell death, breakdown of the skin, and development of the pressure sore.

Other causes may include friction, which is the rubbing that occurs when a person is pulled across bed sheets or other surfaces, and shear, which is movement (such as sliding down a chair) that causes the skin to fold over itself, cutting off the blood supply and possibly causing pressure sores.

Pressure sores develop in four stages :¹

• Stage 1 sores may be painful and tender. The skin may appear reddened or darker than normal, like a bruise, although there are no breaks or tears in the skin.
• At stage 2, the skin breaks open, wears away, or forms an ulcer . It is usually tender and painful. The sore expands into deeper layers of the skin. Some skin may be damaged beyond repair or die at this stage.
• During stage 3, the sore gets worse and moves into the tissue beneath the skin, forming a small crater. The sore usually is not painful at this stage, due to significant tissue damage. However, the risk of infection or tissue death is high.
• At stage 4, the pressure sore is very deep, reaching into muscle and bone and causing extensive damage. The sore is not usually painful at this stage, due to significant tissue death. Your deeper tissues, tendons, and joints may be damaged.

Pressure sores are usually diagnosed with a physical examination. A skin and wound culture or a skin biopsy may be done if your doctor thinks you may have an infection.

You or your caregiver can prevent pressure sores by using proper pressure-relieving supports and devices and changing your position frequently, whether you're in a bed or a wheelchair. For more information, see the topic Pressure Sores.

Contact your health professional if you:

• Notice an increase in the size or drainage of the sore.
• Notice increased redness around the sore or black areas starting to form.
• Notice that the sore begins to smell bad and/or the drainage becomes a greenish color.
• Develop a fever.

Treatment

General treatment for pressure sores consists of keeping the area dry and clean, eating well, and reducing pressure. All pressure sores need to be treated early, because after a sore progresses to stage 3 or 4 , it is difficult to treat and can lead to serious complications. Specific treatment depends on the stage of the pressure sores.

As you treat a pressure sore, you will know it is healing correctly if:

• The sore is getting smaller.
• Pinkish tissue is forming along the edges of the sore, gradually moving toward the center.
• The sore bleeds a little. This indicates blood circulation in the area, which helps healing.

After a pressure sore is healed, it is important to gradually put pressure on the area where the sore had been.

• Apply pressure for no more than 15 minutes and then check the area for redness and, if present, how quickly the redness fades. If fading occurs in 15 minutes or less, no damage has occurred. Before applying pressure to the area again, wait at least 1 hour.
• After three successful 15-minute applications of pressure, you can apply pressure for 30 minutes. Check for redness and how fast it disappears, as noted above.
• If you can do three 30-minute applications successfully, increase the time by 30 minutes a day using the same procedure.
• If an application of pressure is not successful—that is, if redness returns and does not fade within 15 minutes—stay at that level until you can complete three successful applications.

Note: Pressure sores can trigger autonomic dysreflexia, a syndrome characterized by a sudden onset of very high blood pressure and headaches. If not treated promptly and correctly, it may lead to seizures, stroke, and even death. Although autonomic dysreflexia rarely leads to these more serious complications, it is important to know the symptoms and watch for them. Autonomic dysreflexia is more common in people with an injury to the thoracic nerves of the spine or above (T6 or above).

Last updated:	February 22, 2007
Author:	Kathe Gallagher, MSW
Reviewed By:	Adam Husney, MD - Family Medicine, Nancy Greenwald, MD - Physical Medicine and Rehabilitation
Editors:	Kathleen M. Ariss, MS, Pat Truman, MATC