New research provides first evidence that hospital-acquired pressure ulcers are a potent risk factor for poor neurological recovery among patients with acute spinal cord injury (SCI).
This study included 1,282 individuals with spinal cord injury, of which 594 (45.7 per cent) developed pressure ulcers during initial hospitalisation at 20 locations across the country.
“It’s old surgical wisdom that patients who have infections will often develop wound healing problems after surgery. While typical infections in spinal cord injury patients evolve in the lung or the bladder, the skin also can be affected,” said Jan M. Schwab, MD, PhD, co-corresponding author of the study.
“Pressure ulcers often develop in patients with spinal cord injury starting during the early hospitalisation, affecting roughly half of the patients. While under recognised as immunologically active infection site, these wounds also contain bacteria that can spread through the body via the blood stream.”
Schwab is a neurologist and professor of neurology at Ohio State who specialises in the treating individuals with spinal cord injury and researching immune malfunctions interfering with neurological recovery.
“Our study found that patients with pressure ulcers regained significantly less motor function through one year after injury,” said Schwab, who is one of the leaders of Ohio State’s Belford Center for Spinal Cord Injury.
“In addition, their recovery of ‘independence in activities of daily living’ was significantly restricted compared to other patients.”
Pressure ulcers send inflammatory signals throughout the body which may also interfere with healing processes directly at the spinal cord injury site, thereby blocking neurological recovery, said Schwab.
“Our results point to the need to refer acute SCI patients to neurological rehabilitation centres such as Ohio State Dodd Rehabilitation Hospital, with specialised protocols and standards to effectively prevent pressure ulcers,” Schwab said.
During this multi-center study, patients were enrolled from 1996 to 2006 and followed-up until 2016. Patients came from the 20 centers of the prospective SCI Model Systems Database in Birmingham, Alabama.
Key inclusion criteria were acute traumatic cervical SCI with relevant motor impairment as measured by American Spinal Injury Association (ASIA) impairment scale.
Earlier studies by Schwab’s team have shown that SCI patients are immune compromised. As a result, they are more likely to develop infections, such as pneumonia, which delays and blunts their neurological recovery as well.
“We wondered whether just the presence of another inflammatory lesion in the body such as a pressure ulcer – in addition to the spinal cord injury lesion itself – is already sufficient to distract wound healing,” said Schwab, who holds the William E. Hunt, MD & Charlotte M. Curtis Chair in Neuroscience at Ohio State.
The study focused on pressure ulcers that were acquired during the early care phase after SCI spanning surgical or first rehabilitative SCI care.
The primary endpoint for the study focused on the change in the American Spinal Injury Association (ASIA) (motor score at one year after SCI. Secondary endpoints included the recovery of Functional Independence Measure (FIM) motor items at one year after SCI and mortality up to 10 years.
“Patients who develop pressure ulcers face worse long-term disability and increased risk of death,” said co-corresponding author Marcel Kopp, a clinical scientist with Department of Experimental Neurology at Charité in Berlin.
“We believe that preventing pressure ulcers from developing can help protect these patients and lead to improved medical care.”
