SPINE: An Initiative to Reduce Pressure Sore Recurrence

Abstract

The recurrence rate after pressure sore reconstruction remains high. Primary inciting factors can be organized into efforts aimed at wound prevention: spasticity relief, pressure off-loading, infection and contamination prevention, nutrition optimization, and maximizing extremity function. This article presents our detailed protocol, SPINE, to address each inciting factor with a summary of cases at our facility and review best practices from evidence-based medicine in the literature.

Fig. 1.

A 29-year-old tetraplegic man with severe fixed contractures and spasticity from a traumatic brain injury. A‚ Preoperative fixed position of the lower extremities. B, Postoperative placement of external fixator. Thirty pounds of progressive traction was placed to straighten the leg.

Fig. 2.

Incision site for release of hip flexors and hip adductors is placed at their origins. The femoral vessels are bordered medially by the adductor longus and laterally by the sartorius muscle. The retractor is placed under the vessels (A) after the tenotomies have been performed and the hip has been released from its contracted position. The gracilis muscle with skin paddle is used to fill in the defect after tenotomies and hip straightening (B).

Fig. 3.

This patient was sitting on a fitted gel cushion in a power wheelchair during her mapping. Pressure load mapping is important for assessing the risk an individual has for developing an ulcer. A color-coded pressure map is generated by a thin sensor mat placed on the patient’s wheelchair and connected to the tablet that displays the map. Evidence shows that capillary blood flow with normal blood pressure is approximately 32 mm Hg. Thus, any load greater than 32 mm Hg should not be sustained to decrease the risk of pressure ulcer development. This image demonstrates areas at risk for pressure ulcer development‚ most noticeably at the right ischial and trochanteric sites (identified with the lighter blue colors). This is a satisfactory pressure distribution, as the weight from sitting alone will increase pressure on the vessels. Even with the satisfactory pressure distribution, this patient will still require position changes to best prevent ulcer development. An unsatisfactory pressure distribution would contain green/yellow/red colors, indicating higher pressure.

Fig. 4.

50-year-old man with sacral, perineal, and bilateral ischial pressure wounds. Perineal wounds occur after multiple debridements of the ischial prominence or after Girdlestone procedures. This patient underwent reconstruction in multiple stages (A) until all wounds were closed (B). This patient completed the SPINE process and healed completely 1 month after surgery (C).

Fig. 5.

A 59-year-old man in O/Cu group 5. A‚ Preoperative static position of the hand with myostatic contracture of the extensor digitorum communis and extensor pollicis longus muscle bellies preventing wrist or digit flexion. This patient underwent fractional lengthening of the finger extensor tendons and zancolli lasso FDS tendon transfers to improve static and dynamic hand function. B‚ Postoperative static position of the hand. The patient graded his result as having a major improvement in his quality of life.

Fig. 6.

A 34-year-old incomplete tetraplegia man underwent (A) biceps-to-triceps tendon transfer to restore (B) elbow extension. Addition of this function allows the patient to assist with transfers and perform independent pressure off-loading.