Pressure Sores

Pressure sores (bed sores) are an injury to the skin and the tissue under the skin. They are a frequent and sometimes serious complication of a spinal cord injury (SCI). They can range from mild reddening of the skin to severe complications, such as infection of the bone (osteomyelitis) or blood (sepsis). They can be hard to treat and slow to heal.

In people with SCIs, the nerves that normally signal discomfort and alert you to relieve pressure by changing position may no longer work. It is important for you to pay attention to possible pressure sores and change your position frequently when you are sitting or lying down.

Pressure sores are usually caused by unrelieved pressure. They often develop on skin that covers bony areas (such as the hips, heels, or tailbone). Constant pressure on the skin reduces blood supply to the skin and to the tissues beneath the skin. Oxygen and nutrients carried by the blood cannot reach the cells in the tissue, eventually causing cell death, breakdown of the skin, and a pressure sore.

Other causes may include friction, which is the rubbing that occurs when a person is pulled across bed sheets or other surfaces, and shear, which is movement (such as sliding down a chair) that causes the skin to fold over itself, cutting off the blood supply and possibly causing pressure sores.

Pressure sores are described in four stages:¹

• Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it then remove your finger). In a dark-skinned person, the area may appear to be a different color than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 sore can feel either firmer or softer than the area around it.
• At stage 2, the skin usually breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion) or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die.
• In stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.
• At stage 4, the pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.

Pressure sores are usually diagnosed with a physical exam. A skin and wound culture or a skin biopsy may be done if your doctor thinks you may have an infection.

You or your caregiver can help prevent pressure sores by using proper pressure-relieving supports and devices and changing your position frequently, whether you're in a bed or a wheelchair. You can also help prevent pressure sores if you avoid smoking, eat a balanced diet that includes plenty of protein, and control your weight. For more information, see the topic Pressure Sores.

Watch for early signs of a pressure sore. These can include:

• A new area of redness that does not go away within a few minutes of taking pressure off the area.
• An area of skin that is warmer or cooler than the surrounding skin.
• An area of skin that is firmer or softer than the skin around it.

Contact your doctor if you:

• Think a pressure sore is starting and you are not able to adjust your activities and positioning to protect the area.
• Notice an increase in the size or drainage of the sore.
• Notice increased redness around the sore or black areas starting to form.
• Notice that the sore begins to smell bad and/or the drainage becomes a greenish color.
• Have a fever.

Treatment

General treatment for pressure sores is to keep the area dry and clean, eat well, and reduce pressure. All pressure sores need to be treated early, because after a sore progresses to stage 3 or 4, it is hard to treat and can lead to serious complications. Specific treatment depends on the stage of the pressure sores.

As you treat a pressure sore, you will know it is healing correctly if:

• The sore is getting smaller.
• Pinkish tissue is forming along the edges of the sore, gradually moving toward the center.
• The sore bleeds a little. This means there is blood circulation in the area, which helps healing.

After a pressure sore is healed, it is important to gradually put pressure on the area where the sore had been.

• Apply pressure for no more than 15 minutes and then check the area for redness. If redness is present, watch how quickly the redness fades. If fading occurs in 15 minutes or less, no damage has occurred. Before applying pressure to the area again, wait at least 1 hour.
• After three successful 15-minute applications of pressure, you can apply pressure for 30 minutes. Check for redness and how fast it fades, as noted above.
• If you can do three 30-minute applications successfully, increase the time by 30 minutes a day using the same procedure.
• If an application of pressure is not successful—that is, if redness returns and does not fade within 15 minutes—stay at that level until you can complete three successful applications.

Note: Pressure sores can trigger autonomic dysreflexia, a syndrome in which there is a sudden onset of very high blood pressure and headaches. If not treated promptly and correctly, it may lead to seizures, stroke, and even death. Although autonomic dysreflexia rarely leads to these more serious complications, it is important to know the symptoms and watch for them. Autonomic dysreflexia is more common in people with an injury to the thoracic nerves of the spine or above (T6 or above).