A comprehensive educational program for SCI patients and their family/caregivers is essential, including information on etiology, risk factors, proper positioning, equipment (e.g., cushions), complications, and principles of wound prevention, skin care, treatment, and when to seek medical attention. Prevention recommendations include examining the skin over bony prominences at least daily with the use of a mirror as needed, shifting body weight in bed and wheelchair on a regular basis, keeping the skin clean and dry if there is incontinence, having an individually prescribed wheelchair and pressure redistribution cushion or power tilt/recline mechanism, ensuring all equipment is maintained and functioning properly, nutritionally complete diet and maintaining appropriate body weight, stopping smoking, and limiting alcohol intake [134, 146].

Since pressure injuries occur over bony prominences, the site of injury development depends upon the position. When sitting, the ischial tuberosities (ITs) are at greatest risk; while in side lying, the greater trochanters become at risk; and in the supine position, the sacrum, heels, and occiput (especially in infants) are at risk for PI development. Accordingly, the most common sites of PIs after SCI change based on the amount of time spent in a given position. Acutely after injury, the most common sites are the sacrum, followed by the heels and ischium. At 1 year, the most common sites are the sacrum, ischium, heels, and trochanters and, at year two post-injury, the ischium, sacrum, and trochanters. When in bed, an appropriate mattress should be sought. Pillows can be used to provide additional padding or provide pressure reduction over bony prominences. Most commonly prescribed early after injury is a turn frequency in bed every 2 h. Once discharged, it is common to extend the 2 h turn schedule although there is no documented protocol for this. The prone position has a large surface area of low pressure and is recommended in the chronic patients as tolerated.

Weight shifting, redistributing the pressure off of the IT to other areas to allow for reperfusion of the ischial areas, is extremely important when the patient is seated in the wheelchair and can be performed by the patient via a number of techniques including an anterior, lateral, or push-up weight shift. If the patient is unable to perform their own weight shift, a caregiver can assist or tilt the chair posteriorly so that the patient’s weight is no longer on their IT.

While there is no absolute regarding the frequency and duration required for weight shifting while in the wheelchair, it is recommended that weight shifts be performed every ~15 min for >2 min to allow for adequate tissue reperfusion [147–149]. A weight shift in a tilt-in-space wheelchair should be >35° when combined with recline at 100°, or >25° when combined with recline at 120° [150]. This degree of tilt does not seem to increase pressure significantly over the sacrum [149]. When performing a tilt weight shift without any recline mechanism, a minimum of 45° is required for adequate pressure distribution [151].

Cushion selection is extremely important. No one cushion is suitable for all individuals with SCI, and prescription should be based on a combination of pressure mapping results, clinical knowledge of the prescriber, and patient preferences.

The general principles of PI treatment are to relieve pressure; eliminate reversible underlying predisposing conditions; avoid friction, shear, and tissue maceration; keep the wound bed moist; manage excessive drainage; and debride devitalized tissue [134, 152] (Table 18.2). In general, stage 1 and 2 PIs are usually treated with local care nonsurgically. Stage 3 and 4 PIs, because of their high rate of recurrence as well as the long duration necessary for wound closure, often require surgical intervention. Involvement of a wound care team early after a pressure ulcer (especially grade 3 and 4) has developed is important.

Silver, available in multiple forms (gel, cream of foam), is a nonselective broad-spectrum topical agent that covers gram-positive and gram-negative microorganisms in the management of colonized and locally infected wounds [153]. Silver-impregnated dressings are contraindicated in neonates, in pregnancy, in patients with significant renal or hepatic impairment, and in those with sensitivity to sulfonamides or large open wounds [154].

Systemic antibiotics are generally only warranted when there is bacteremia, sepsis, advancing cellulitis, or osteomyelitis. Swab cultures are not useful in determining the presence of infection of PIs and only reflect the bacteria on the surface of the ulcer. Tissue biopsy can determine if there are bacteria within the tissue, and if the bacterial count is greater than 10⁵, wound healing may be impaired. Advancing cellulitis is indicative of invasive tissue infection and must be treated with appropriate antibiotics.

Approximately 25 % of nonhealing PIs have underlying osteomyelitis, and this should be ruled out if there is reasonable suspicion. Bone biopsy remains the definitive method to diagnose osteomyelitis and identifies the organism, although surgeons are often reluctant to perform this unless there are other compelling indications for surgery. The most common organisms isolated from PIs are Proteus mirabilis, group D streptococci, E. coli, Staphylococcus, Pseudomonas species, and Corynebacterium organisms. Conventional bone scan is more sensitive for osteomyelitis than plain films, although specificity is approximately 50 % because of difficulty differentiating soft tissue infection from bone infection. Indium leukocyte scans improve the sensitivity and specificity. MRI has greater sensitivity and specificity. Treatment of osteomyelitis includes appropriate antibiotics for 6–12 weeks.

While there are numerous adjunctive therapies, only electrical stimulation has merited recommendation and can be considered for clean stage 2, 3, and 4 injuries that are unresponsive to conventional therapy. Electrical stimulation accelerates the healing rate of ulcers when combined with standard wound management [144]. The therapeutic efficacy of hyperbaric oxygen; infrared, ultraviolet, and low-energy laser irradiation; and ultrasonography has not been sufficiently established for recommendation. Ultrasound/ultraviolet C can be considered as an adjunct treatment when PIs are not healing with standard wound care post-SCI.

Platelet-derived growth factors (PDGF) can be applied directly to the wound surface to promote growth of skin, soft tissue, and blood vessels. Becaplermin (Regranex), a commercially prepared biotechnology product with recombinant PDGF as the active ingredient, in conjunction with good wound care, is efficacious in accelerating wound closure of chronic diabetic ulcers [155, 156]. This product, however, carries a warning indicating that patients who use in excess of three tubes may experience increased mortality due to malignancy.

Negative-pressure wound therapy (NPWT) distributes negative (subatmospheric) pressure across a wound surface to promote healing in clean stage III and IV wounds. An airtight system is created using special foam, sterile tubing and canister, and an adhesive film drape. The negative pressure in the wound bed increases blood flow, reduces local tissue edema, decreases bacterial colonization, and increases granulation tissue formation and mechanical wound closure [144]. It is contraindicated on wounds with exposed vital structures, necrotic material, and significant purulence or if it leads to bleeding complications.

Proper selection of the surgical candidate is important because of the cost and postoperative recovery time, both of which can be extensive. In addition, if musculocutaneous flaps are performed, there are only a limited number that can be performed, which may be of consequence if the individual has repeated PIs.

Musculocutaneous and fasciocutaneous flaps are the procedure of choice for SCI patients who require surgical closure of the pressure injury. Because of their blood supply, these flaps are better able to withstand pressure and shear and can be particularly useful in osteomyelitis, by bringing highly vascularized muscle tissue into the area of infection. The decision to use a particular flap or type depends on the surgeons’ expertise and the size and location of the injury. It is important to approach issues that impair postoperative healing that include smoking, spasticity, nutritional concerns, and bacterial colonization (contamination from urine and feces). If there is a great deal of stool incontinence interfering with the wound, or suspected to interfere with postoperative healing of pressure injuries over the sacrum and ischial tuberosities, a temporary diverting colostomy may be considered, although most pressure injuries heal postoperatively without such procedures [157].

At the sacral area, the gluteus maximus muscle may be used entirely or in portions. At the ischium, a posterior thigh fasciocutaneous flap, inferior gluteus maximus myocutaneous flap, hamstring V-Y advancement flap, and tensor fascia lata fasciocutaneous flap can all be used to cover defects in this region. Prophylactic unilateral or bilateral ischiectomy is not recommended. At the greater trochanter, the tensor fascia lata fasciocutaneous flap is considered the flap of choice, although alternatives include the use of the vastus lateralis, inferior gluteus maximus, and rectus femoris muscles.

Postoperatively, strict bed rest is prescribed on a low-air-loss mattress or an air-fluidized bed, maintaining pressure off the surgical site as much as possible. For repairs of the sacrum or IT, the head of the bed should not be elevated greater than 15° since this position increases the risk of shear on the repaired ulcer site. There is no consensus in the literature on the necessary length of immobilization post-flap, which varies based on the size of the flap as well as the individual protocols and ranges from 2–6 weeks. Once healing occurs, passive range of motion (ROM) of the hips in preparation for sitting can be initiated. Once the hip ROM is at 90° without stress on the surgical site, sitting is initiated in short intervals, i.e., 15 min, and then with return to bed for evaluation of the surgical site. A progressive sitting program ensues, with an increase in sitting by 15 min once to twice per day. While institutional protocols vary, usually over a course of 2–3 weeks, the patient can progress to sitting up to 5 h/day completing the full protocol up to 8½ weeks [158]. Postoperative complications are common. In a recent study of post-flap complications, they found that the overall rate was 21 %, with suture dehiscence as the most common (31 %) followed by infection (25 %) [159].

Pressure injury recurrence is common and most frequently recurs at the ischial tuberosities. Smoking, diabetes mellitus, and cardiovascular disease are associated with the highest rates of recurrence.

While men and women remain interested in sexual activity after SCI, their level of desire and frequency of activity decreases [160]. Regaining sexual function is extremely important and is an area of unmet need for persons with SCI [160–162]. It is reported to be the highest priority among individuals with paraplegia and the second highest priority, after regaining arm and hand function, among individuals with tetraplegia [161]. As such, knowledge of this topic and discussion with patients at the appropriate time are extremely important.