Retrospective cohort study Objectives: to describe the incidence and the associated risk factors of post-surgical complications and recurrence in individuals with spinal cord injury/disorder (SCI/D) presenting deep pressure injuries (PIs), treated with a specific surgical and rehabilitation treatment protocol.
Tertiary Rehabilitation Hospital for SCI/D in Italy. Methods: Retrospective analysis of the medical records of adult individuals with SCI/D, who developed a PI after the first discharge from a Spinal Unit, underwent flap surgery for PI between July 2011 and January 2018. The statistical unit of analysis was the surgical intervention. Logistic regression analysis with robust standard errors was performed to assess risk factors of post-surgical complications.
434 surgical intervention records were included, for a total of 378 patients. The treated PIs were ischiatic in 56.2% of the cases, sacral in 32.5%, trochanteric in 15.7%, and 5.8% were in other sites. In 239 cases (55.1%) a histological diagnosis of osteomyelitis was confirmed. Minor complications occurred in 13.6% of interventions, while major complications were 3.9%. Sacral PI (OR = 2.55, 95%CI: 1.50–4.35) and muscular/musculocutaneous flap (OR = 2.12, 95%CI: 1.05–4.28) were significant factors associated with risk of post-surgical complications. After a mean follow-up of 21 months (range 12–36), six people (1.4%) had a recurrence. Patients with a recurrence had at least one comorbidity compared to 57% of people without recurrences (p = 0.036).
Our results demonstrate that complication and recurrence rates can be minimized when an established interdisciplinary and rehabilitation protocol is integrated in the clinical management.
This is a preview of subscription content, access via your institution
Subscribe to this journal
Receive 12 print issues and online access
$259.00 per year
only $21.58 per issue
Rent or buy this article
Get just this article for as long as you need it
Prices may be subject to local taxes which are calculated during checkout
The data sets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.
Cowan LJ, Ahn H, Flores M, Yarrow J, Barks LS, Garvan C, et al. Pressure Ulcer Prevalence by Level of Paralysis in Patients With Spinal Cord Injury in Long-term Care. Adv Ski Wound Care. 2019;32:122–30.
Gélis A, Dupeyron A, Legros P, Benaïm C, Pelissier J, Fattal C, et al. Pressure ulcer risk factors in persons with spinal cord injury Part 2: the chronic stage. Spinal Cord. 2009;47:651–61. https://doi.org/10.1038/sc.2009.32
DeVivo Michael FarrisV. Causes and Costs of Unplanned Hospitalizations Among Persons with Spinal Cord Injury. Top Spinal Cord Inj Rehabil. 2011;16:53–61.
White BAB, Dea N, Street JT, Cheng CL, Rivers CS, Attabib N, et al. The Economic Burden of Urinary Tract Infection and Pressure Ulceration in Acute Traumatic Spinal Cord Injury Admissions: Evidence for Comparative Economics and Decision Analytics from a Matched Case-Control Study. J Neurotrauma. 2017;34:2892–2900.
Kriz J, Sediva K, Maly M. Causes of death after spinal cord injury in the Czech Republic. Spinal Cord. 2021;59:814–20.
Wu-Fienberg Y, Henzel MK, Richmond MA, Becker DB. Impact of interdisciplinary rounds in the spinal cord injury unit on relational coordination for patients with pressure injury: A pilot study. J Spinal Cord Med. 2019;42:245–50.
Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M, et al. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Cont Nurs. 2016;43:585–97. https://doi.org/10.1097/WON.0000000000000281
Kruger EA, Pires M, Ngann Y, Sterling M, Rubayi S. Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends. J Spinal Cord Med. 2013;36:572–85. https://doi.org/10.1179/2045772313Y.0000000093
Jordan SW, De la Garza M, Lewis VL Jr. Two-stage treatment of ischial pressure ulcers in spinal cord injury patients: Technique and outcomes over 8 years. J Plast Reconstr Aesthet Surg. 2017;70:959–66. https://doi.org/10.1016/j.bjps.2017.01.004.
Kreutzträger M, Voss H, Scheel-Sailer A, Liebscher T. Outcome analyses of a multimodal treatment approach for deep pressure ulcers in spinal cord injuries: a retrospective cohort study. Spinal Cord. 2018;56:582–90. https://doi.org/10.1038/s41393-018-0065-3.
Mohamad Hashim N, Yusof ANM, Engkasan JP, Hasnan N. Factors affecting adherence to behaviours appropriate for the prevention of pressure injuries in people with spinal cord injury from Malaysia: a qualitative study. Spinal Cord. 2021;59:777–86.
Brunel A-S, Lamy B, Cyteval C, Perrochia H, Téot L, Masson R, et al. Diagnosing pelvic osteomyelitis beneath pressure ulcers in spinal cord injured patients: a prospective study. Clin Microbiol Infect. 2016;22:267.e1–267.e8.
Tedeschi S, Negosanti L, Sgarzani R, Trapani F, Pignanelli S, Battilana M, et al. Superficial swab versus deep-tissue biopsy for the microbiological diagnosis of local infection in advanced-stage pressure ulcers of spinal-cord-injured patients: a prospective study. Clin Microbiol Infect. 2017;23:943–7.
Summo V, Sgarzani R, Negosanti L, Fabbri E, Vietti Michelina V, Villani R, et al. Pressure Ulcers in Patients with Spinal Cord Injuries: Concordance Between Swab and Intraoperative Culture. Plast Reconstr Surg Glob Open. 2016;4:e651.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13. https://doi.org/10.1097/01.sla.0000133083.54934.ae.
Singh R, Singh R, Rohilla RK, Magu NK, Goel R, Kaur K, et al. Improvisations in classic and modified techniques of flap surgery to improve the success rate for pressure ulcer healing in patients with spinal cord injury. Int Wound J. 2013;10:455–60.
Srivastava A, Gupta A, Taly AB, Murali T. Surgical management of pressure ulcers during inpatient neurologic rehabilitation: outcomes for patients with spinal cord disease. J Spinal Cord Med. 2009;32:125–31.
Lindqvist EK, Sommar P, Stenius M, Lagergren JF. Complications after pressure ulcer surgery - a study of 118 operations in spinal cord injured patients. J Plast Surg Hand Surg. 2020;54:145–50.
Morel J, Herlin C, Amara B, Mauri C, Rouays H, Verollet C, et al. Risk factors of pelvic pressure ulcer recurrence after primary skin flap surgery in people with spinal cord injury. Ann Phys Rehabil Med. 2019;62:77–83.
Paker N, Buğdaycı D, Gökşenoğlu G, Akbaş D, Korkut T. Recurrence rate after pressure ulcer reconstruction in patients with spinal cord injury in patients under control by a plastic surgery and physical medicine and rehabilitation team. Turk J Phys Med Rehabil. 2018;64:322–7.
Tadiparthi S, Hartley A, Alzweri L, Mecci M, Siddiqui H. Improving outcomes following reconstruction of pressure sores in spinal injury patients: a multidisciplinary approach. J Plast Reconstr Aesthet Surg. 2016;69:994–1002.
Ljung AC, Stenius MC, Bjelak S, Lagergren JF. Surgery for pressure ulcers in spinal cord-injured patients following a structured treatment programme: a 10-year follow-up. Int Wound J. 2017;14:355–9. https://doi.org/10.1111/iwj.12609
Biglari B, Büchler A, Reitzel T, Swing T, Gerner HJ, Ferbert T, et al. A retrospective study on flap complications after pressure ulcer surgery in spinal cord-injured patients. Spinal Cord. 2014;52:80–3.
Gruber S, Whitworth AB, Kemmler G, Papp C. New risk factors for donor site seroma formation after latissimus dorsi flap breast reconstruction:: 10-year period outcome analysis. J Plast Reconstr Aesthet Surg. 2011;64:69–74. https://doi.org/10.1016/j.bjps.2010.03.032.
King SJ, Bentz TW, Afifi ML, Reconstructive AM. surgery and patients with spinal cord injury: Perioperative considerations for the plastic surgeon. J Plast Surg Hand Surg. 2016;50:44–9. https://doi.org/10.3109/2000656X.2015.1071261.
Rigazzi J, Fähndrich C, Osinga R, Baumgartner S, Baumberger M, Krebs J, et al. Osteomyelitis and antibiotic treatment in patients with grade IV pressure injury and spinal cord lesion-a retrospective cohort study. Spinal Cord. 2022;60:540–7. https://doi.org/10.1038/s41393-022-00758-1.
Singh R, Singh R, Rohilla RK, Siwach R, Verma V, Kaur K, et al. Surgery for pressure ulcers improves general health and quality of life in patients with spinal cord injury. J Spinal Cord Med. 2010;33:396–400.
We aknowlegde for their contribution in the multidisciplinary treatment protocol developement and the constant team work Montecatone wound care team (Alba Boriello, Carlo Golinelli, Luca Spallone, Debora Donattini, Rita Capirossi), the physiotherapists Chiara Poletti and Barbara Oles and the phisicians Carlo Frondini, Cristina Orlandini, Gaetano Vetrone, Romano Linguerri, Emilio Emili, Francesco Costa, Mahmoud Ganem Sadam. Also thanks to Tiziana Giovannini and Cecilia Baroncini for their contribution.
All contributing authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this paper.
We certify that all applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during the course of this research, that was approved by the Institutional Ethical Committee AVEC with the reference number 1000-2020-OSS-AUSLIM on 19th November 2020.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Sgarzani, R., Maietti, E., Tedeschi, S. et al. Multidisciplinary treatment protocol for ischiatic, sacral, trochanteric or other pressure injuries in people with spinal cord injury: a retrospective cohort study. Spinal Cord 61, 204–210 (2023). https://doi.org/10.1038/s41393-022-00869-9