Multidisciplinary approach in surgical pres­sure ulcer ther­apy after spinal cord injury


Multidisciplinární přístup v chirurgické léčbě dekubitů u pa­cientů s míšní lézí

Chirurgická léčba rozsáhlých dekubitů u pa­cientů s traumatickou míšní lézí stále představuje velkou výzvu a často opomíjenou kapitolu, s níž je celá řada odborností den­ně konfrontována. Léčba pa­cientů často vyžaduje multidisciplinární spolupráci napříč nejen chirurgickými obory. Právě úzká spolupráce s výživovým specialistou, mikrobio­logem a pracovníky z chirurgických oborů je mnohdy jedinou možností k úspěšné terapii. Cílem příspěvku je ve stručnosti shrnout základní parametry multidisciplinární spolupráce při léčbě rozsáhlých dekubitů u pa­cientů s míšní lézí. Výše zmíněný přehled v krátkosti demonstrujeme na sérii kazuistik z naší každoden­ní praxe. V diskuzi se zabýváme rolí jednotlivých chirurgických specializací, významem nutriční podpory a řešením infekčních komplikací.

Klíčová slova:

dekubity – míšní poranění – infekce – výživa – multidisciplinární spolupráce


Authors: P. Šín 1,2;  J. Holoubek 1,2;  A. Hokynková 1,2;  B. Lipový 1,2
Authors‘ workplace: Department of Burns and Plastic Surgery, University Hospital Brno, Czech Republic 1;  Faculty of Medicine, Masaryk University, Brno, Czech Republic 2
Published in: Cesk Slov Neurol N 2019; 82(Supplementum 1): 52-55
Category: Original Paper
doi: 10.14735/amcsnn2019S52

Overview

Surgical treatment of extensive pres­sure ulcers in patients with spinal cord injury still represent a major chal­lenge and often neglected part of care with which many experts is confronted daily. Treatment of these patients often requires extensive multidisciplinary approach acros­s, not only, surgical disciplines. Close cooperation with a nutritionist, microbio­logist and other surgical specialists is often the only way to succes­sful­ly manage the problem. The aim of this publication is to briefly sum­marize the basic parameters in multidisciplinary col­laboration in the treatment of large pres­sure ulcers in patients with spinal cord lesions. We then briefly demonstrate the above mentioned is­sues on a series of case reports result­­ing from our daily practice and then discuss the role of individual surgical specializations, the importance of nutritional support and the solution of infectious complications.

Keywords:

pressure ulcers – spinal cord injury – infection – nutrition – multidisciplinary approach

Introduction

Pres­sure ulcers after spinal cord injury (SCI) represent a dif­ficult problem lead­­ing to repeated hospitalizations, multiple operations and potential­ly devastat­­ing complications. This problem presents a chal­lenge for patients, nurses and doctors [1]. Patients with SCI and its as­sociated comorbidities are among the highest risk population for develop­­ing pres­sure ulcers. The incidence of pres­sure ulcers in the SCI population is 25– 66% [2,3].

In this publication we describe the need for extensive multidisciplinary approach in surgical treatment of pres­sure ulcers in SCI patients. In the individual chapters we describe the importance of nutritional support, microbio­logical surveil­lance and interdisciplinary cooperation within the surgical closure of the defect. We then demonstrate the discus­sed topics with several examples based on our clinical practice.

Case series

Case report 1

A 68-year-old paraplegic patient was admitted to our clinic in septic condition with an extensive pres­sure ulcer in the sacral region (Fig. 1). Multiple necrectomy of the whole region was performed and intensive antibio­tic ther­apy was introduced (further adjusted accord­­ing to the results of cultivation and antibio­tic sensitivity). Due to repeated contamination of the wound with stools (within closed distance of anus) and mainly the presence of the posterior wall of the rectum just below the bottom of the defect, it was decided that a sigmoidostomy would be created by a general surgeon. The condition was further complicated by the development of the ileus state, with the neces­sity of surgical revision due to rotation and malposition of intestinal loops. Derotation, de­suflasion and re-suture were performed dur­­ing revision surgery. Fol­low­­ing the surgery, the post-operative period was un­eventful. The closure of the pres­sure ulcer in such a stres­sful situation and under these conditions would be a high risk, especial­ly in cases of wound heal­­ing in fields that have been re-operated several times. By this point, the patient was in malnutrition, hypoproteinemia and all his reserves were exhausted. Therefore, a conservative approach and intensive cor­rection of all macro- and micronutrients was priority. Surgical closure of the wound was postponed for several weeks after the patient’s complete realimentation. The final wound closure was performed one month later. The entire defect was covered by a large fasciocutaneous flap from the left half of the sacral/ gluteal region (Fig. 2). The whole hospitalization period was managed under precise microbio­logical surveil­lance and targeted antibio­tic ther­apy.

Large and deep pressure ulcer in whole sacral region.<br>
Obr. 1. Rozsáhlý dekubitus postihující prakticky celou oblast sakra
a hýždí.
1. Large and deep pressure ulcer in whole sacral region.
Obr. 1. Rozsáhlý dekubitus postihující prakticky celou oblast sakra a hýždí.

Defect after closure with large transposition flap.<br>
Obr. 2. Defekt po definitivním uzávěru transpozičním lalokem.
2. Defect after closure with large transposition flap.
Obr. 2. Defekt po definitivním uzávěru transpozičním lalokem.

Case report 2

As our second case, we present a 43-year-old paraplegic man, who was admitted to our clinic with large infected pres­sure ulcers in the sacral and right trochanteric region (Fig. 3). Both defects were severely contaminated by multiresistant strains of Pseudomonas aerugi­nosa and Acinetobacter baumanii, which required prolonged and chal­leng­­ing antibio­tic ther­apy with close cooperation with the Department of Clinical Microbio­logy. Preoperative examination and CT scans showed extensive osteomyelitis in the right proximal femur. In cooperation with an orthopedic surgeon, we performed radical resection of the proximal femur and subsequently radical necrectomy of both defects. At first, we decided to close the smal­ler and more superficial defect in the sacral region with a V-Y fasciocutaneous flap. In the trochanteric region, the defect was large and deep so we decided to apply NPWT (Negative Pres­sure Wound Ther­apy) for promot­­ing granulation and remediation of infection. We sustained the vacuum as­sisted closure ther­apy for several weeks, together with intense nutrition support. Final­ly, after 1 month we could close the defect with a large transposition flap (Fig. 4). Further heal­­ing and the post-operative period were without any complication.

Large trochanteric defect with luxated femur. Picture after
osteotomy of proximal femur, including caput femoris.<br>
Obr. 3. Rozsáhlý trochanterický dekubitus s dominující luxovanou
kyčlí. Obrázek již po provedené osteotomii hlavy a proximální
části femuru.
3. Large trochanteric defect with luxated femur. Picture after osteotomy of proximal femur, including caput femoris.
Obr. 3. Rozsáhlý trochanterický dekubitus s dominující luxovanou kyčlí. Obrázek již po provedené osteotomii hlavy a proximální části femuru.

Peroperation picture after elevation of large fasciocutaneous
flap for closure of trochanteric defect.<br>
Obr. 4. Peroperační snímek elevace fasciokutánního laloku k uzávěru
trochanterického dekubitu.
4. Peroperation picture after elevation of large fasciocutaneous flap for closure of trochanteric defect.
Obr. 4. Peroperační snímek elevace fasciokutánního laloku k uzávěru trochanterického dekubitu.

Discus­sion

University Hospital Brno provides one of four SCI in the Czech Republic. As a part of this service, a multidisciplinary surgical team was established for the surgical management of pres­sure ulcers aris­­ing in this patient group. Despite the grow­­ing pos­sibilities of conserva­tive ther­apy, the extensive pres­sure ulcers of grades III and IV can only be closed by surgical excision and reconstruction. Due to the fact that such an intervention is general­ly an elective surgical procedure, patient’s over­all condition and chronic medical comorbidities (e. g. diabetes mel­litus, hypertension, malnutrition, and anemia) have to be compensate by the multidisciplinary team before a patient is considered a good candidate for surgery [1]. If the ulcer or ulcers are in close proximity to the anus, clinical judgment should address the need for bowel diversion by colostomy. The presence of stool significantly compromises wound heal­­ing and makes its toilet virtual­ly impos­sible. Furthermore, the close proximity of the rectum to the defect may complicate the surgical procedure and its pos­sible perforation may result in fatal complications [4]. The same applies to the perineal region –  the creation of a temporary or permanent urinary diversion should be considered here. The presence of an orthopedic surgeon is often required due to osteomyelitis, which will also have a significant impact on further surgical plans. Often, a radical osteotomy is required before final wound closure [5]. Only after proper radical surgical debridement, includ­­ing of bone structures and conceiv­­ing a proper surgical field, the defect can be closed by a plastic surgeon. Surgical management of pres­sure ulcer closure involves a spectrum of options, from simple debridement with direct closure, to skin grafting, fasciocutaneous flaps, myocutaneous flaps or even free flaps [1]. The choice of flap reconstruction always depends on a number of factors such as anatomical location, reoperated ter­rain, general condition and surgeon‘s preference [4]. Consider­­ing the spectrum of patients with often neglected chronic wounds and a very poor over­all condition, it is clear that the result­­ing surgical ef­fect is burdened with a cor­respond­­ing percentage of complications and recur­rences. Scientific sources show dif­ferent percentages of complications. For example, Sameem et al reports complications rang­­ing from 9– 20%, depend­­ing on the type of flap chosen. The most frequent complications in their study were flap necrosis (partial), wound dehiscence, infection and recur­rence of pres­sure ulcer [6]. The ideal nutritional intake continues to be discus­sed to this day. Energy, protein, arginine, and micronutrients are all es­sential for proper wound healing. Proteins play the most important role in the heal­­ing process and are es­sential in the fibroblast proliferation proces­s, angiogenesis, col­lagen synthesis and over­all in tis­sue reparation [7], In 2009, National Pres­sure Ulcer Advisory Panel introduced general guidelines for the treatment and prevention of pres­sure ulcers, these were updated in 2014 [8]. For pres­sure ulcer stage III/ IV, recom­mended protein intake goes up to 2 g/ kg. The key role of protein intake is well demonstrated in a study presented by Crowe et al [9]. The group receiv­­ing higher protein (1.8 g protein per kg body weight) demonstrated nearly a two-fold greater rate of heal­­ing than those ran­domized to lower protein intake (1.2 g protein per kg body weight). The role of carbohydrates, fats and micronutrients is equal­ly important. To prevent protein-energy malnutrition and improve wound healing, the diet should be adequate in energy in the form of carbohydrates, fat and protein. Infection of a pres­sure ulcer may result in soft tis­sue and bone infections: cel­lulitis, abscess formation, bursitis, and osteomyelitis of bone underly­­ing the wound bed [10]. In SCI patients, it is one of the most com­mon causes of bacteremia [11]. Control of wound colonization and infection should always be one of the biggest priorities in treatment protocol [1]. Precise microbio­logical surveil­lance should be strictly conducted in all patients, along with targeted antibio­tic administration based on sensitivity. This is the only way to prevent an increase in antibio­tic resistance and at the same time to succes­sful­ly eradicate pathogens in an ef­fort to prevent further dis­semination [12].

Conclusion

Surgical treatment of pres­sure ulcers in patients after SCI is often a very complicated process involv­­ing many aspects of surgery. Today, cor­rect and ef­fective treatment is pos­sible due to large col­laboration in a multidisciplinary team. It is the presence of a diverse range of experts, not only from the surgical field, that has contributed to the development in this often neglected is­sue.

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manu­script met the ICMJE “uniform requirements” for biomedical papers.

Accepted for review: 30. 6. 2019

Accepted for print: 4. 7. 2019

Alica Hokynková, MD

Department of Burns and Plastic Surgery

University Hospital Brno

Jihlavská 20

625 00, Brno

Czech Republic

e-mail: alicah@post.cz


Sources

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2. Fuhler M, Garber S, Rintala D et al. Pres­sure ulcers in com­munity-resident persons with spinal cord injury: prevalence and risk factors. Arch Phys Med Rehabil 1993; 74(11): 1172– 1177.

3. Regan M, Teasell R, Dalton L et al. A systematic review of therapeutic interventions for pres­sure ulcers after spinal cord injury. Arch Phys Med Rehabil 2009; 90(2): 213– 231. doi: 10.1016/ j.apmr.2008.08.212.

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6. Sameem M, Au M, Wood T et al. A systematic review of complication and recur­rence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pres­sure sores. Plast Reconstr Surg 2012; 130(1): 67e– 77e. doi: 10.1097/ PRS.0b013e318254b19f.

7. Antalová N, Pokorná A, Hokynková A et al. Factors influenc­­ing recur­rence of the pres­sure ulcers after plastic surgery –  retrospective analysis. Cesk Slov Neurol N 2018; 81/ 114: S23. doi: 10.14735/ amcsn­n2018S23.

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Labels
Paediatric neurology Neurosurgery Neurology

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