A potential widespread and important role for sleep-disordered breathing in pressure injury development and delayed healing among those with spinal cord injury


Soft tissue pressure injuries commonly occur in those with spinal cord injury. They add an immeasurable medical, emotional, and social burden to those who suffer a spinal cord injury and ultimately can cause death due to sepsis when they ulcerate and become infected. Hence it is notable that (i) obstructive sleep apnea and other forms of sleep-disordered breathing are highly prevalent among those with spinal cord injury; (ii) several of the pathophysiologic consequences of sleep-disordered breathing, including hypoxemia, ischemia, oxidative stress, and endothelial dysfunction, would be expected to increase susceptibility to pressure injuries, worsen their severity, and slow or prevent their healing; and (iii) there is emerging clinical evidence that sleep-disordered breathing can have a significant role in the pathogenesis of other types of chronic wounds and that treatment of sleep-disordered breathing can aid in the healing of these wounds. These findings raise the possibility that sleep-disordered breathing may have a widespread and important role in the development, severity, and persistence of pressure injuries in those with spinal cord injury and that treatment of sleep-disordered breathing may be an effective adjunct in their prevention and healing. Studies to determine if there is a functional relationship between sleep-disordered breathing and pressure injuries in individuals with spinal cord injury are warranted.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.


  1. 1.

    International review. Pressure ulcer prevention: pressure, shear, friction and microclimate in context. A consensus document. London: Wounds International; 2010.

    Google Scholar 

  2. 2.

    Taylor R, James T. The role of oxidative stress in the development and persistence of pressure ulcers. In: Bader DL, Bouten CVC, Colin D, Oomens CWJ, editors. Pressure ulcer research: current and future perspectives. Berlin Heidelberg: Springer; 2005. p. 205–32.

  3. 3.

    Byrne DW, Salzberg CA. Major risk factors for pressure ulcers in the spinal cord disabled: a literature review. Spinal Cord. 1996;34:255–63.

    CAS  Article  Google Scholar 

  4. 4.

    Sankari A, Vaughan S, Bascom A, Martin JL, Badr MS. Sleep-disordered breathing and spinal cord injury: a state-of-the-art review. Chest. 2019;155:438–45.

    Article  Google Scholar 

  5. 5.

    Shamsuzzaman ASM, Gersh BJ, Somers VK. Obstructive sleep apnea: implications for cardiac and vascular disease. JAMA. 2003;290:1906–14.

    CAS  Article  Google Scholar 

  6. 6.

    Lavie L. Obstructive sleep apnoea syndrome-an oxidative stress disorder. Sleep Med Rev. 2003;7:35–51.

    Article  Google Scholar 

  7. 7.

    Hoyos CM, Melehan KL, Liu PY, Grunstein RR, Phillips CL. Does obstructive sleep apnea cause endothelial dysfunction? A critical review of the literature. Sleep Med Rev. 2015;20:15–26.

    Article  Google Scholar 

  8. 8.

    Unnikrishnan D, Jun J, Polotsky V. Inflammation in sleep apnea: an update. Rev Endocr Metab Disord. 2015;16:25–34.

    CAS  Article  Google Scholar 

  9. 9.

    Larouche J, Sheoran S, Maruyama K, Martino MM. Immune regulation of skin wound healing: mechanisms and novel therapeutic targets. Adv Wound Care. 2018;7:209–31.

    Article  Google Scholar 

  10. 10.

    Mustoe TA, O’Shaughnessy K, Kloeters O. Chronic wound pathogenesis and current treatment strategies: a unifying hypothesis. Plast Reconstr Surg 2006;117(Suppl 7):35S–41S.

    CAS  Article  Google Scholar 

  11. 11.

    Patt BT, Jarjoura D, Lambert L, Roy S, Gordillo G, Schlanger R, et al. Prevalence of obstructive sleep apnea in patients with chronic wounds. J Clin Sleep Med. 2010;6:541–4.

    Article  Google Scholar 

  12. 12.

    Altaf Q-AA, Ali A, Piya MK, Raymond NT, Tahrani AA. The relationship between obstructive sleep apnea and intra-epidermal nerve fiber density, PARP activation and foot ulceration in patients with type 2 diabetes. J Diabetes Complicat. 2016;30:1315–20.

    Article  Google Scholar 

  13. 13.

    Maltese G, Fountoulakis N, Drakatos P, Shah D, Patel K, Sharma A, et al. Elevated obstructive sleep apnoea risk score is associated with poor healing of diabetic foot ulcers: a prospective cohort study. Diabet Med. 2018;35:1494–8.

    CAS  Article  Google Scholar 

  14. 14.

    Vas PRJ, Ahluwalia R, Manas AB, Manu CA, Kavarthapu V, Edmonds ME. Undiagnosed severe sleep apnoea and diabetic foot ulceration - a case series-based hypothesis: a hitherto under emphasized factor in failure to heal. Diabet Med. 2016;33:e1–4.

    CAS  Article  Google Scholar 

Download references

Author information




SJW conceived the work; SJW and SXC drafted and revised the paper, approved the final version and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Steven J. Weintraub.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Weintraub, S.J., Chen, S.X. A potential widespread and important role for sleep-disordered breathing in pressure injury development and delayed healing among those with spinal cord injury. Spinal Cord 58, 626–629 (2020). https://doi.org/10.1038/s41393-020-0434-6

Download citation