Pressure Injuries: Thirty Times the Death Rate

Pressure injuries after spinal cord injury: thirty times the death rate, and the surface nobody checks

The 70-year British study of mortality after traumatic spinal cord injury, published in Spinal Cord in 2017 and following 5,483 people, compared age-standardised death rates in this population against the general population of England and Wales in 2014.

Respiratory causes ran about five times higher. Urogenital causes about twelve times. Circulatory causes twice.

Skin causes ran about thirty times higher.

Thirty. Not cancer, not heart disease, not the respiratory complications that are the leading cause of death in absolute terms. The largest relative excess of any cause of death after spinal cord injury is skin.

And skin injury is almost entirely preventable. That is what makes the number so difficult to look at.

Supporting evidence from the SCIRE Project’s review of the literature fills in the picture. Annual prevalence of pressure injuries after spinal cord injury has been reported across studies from 10.2 to 38 per cent. Around 7 to 8 per cent of people who develop a pressure injury die from related complications. Risk stays roughly steady for the first ten years after injury and then increases at fifteen years. Rehospitalisation for pressure injuries has been found to peak around five years after discharge from initial rehabilitation. Grade III and IV injuries — the deep ones — become more common after fifteen years. The sacrum is the most frequent site. Tetraplegia carries a higher burden than paraplegia.

So this is not an acute-phase problem that gets solved in rehab. It is a lifelong risk that gets worse with time, peaks in rehospitalisation terms five years after everybody has stopped paying close attention, and has the highest relative mortality of anything on the list.

We support people with spinal cord injury across New South Wales, including pressure care under clinical plans written by the person’s treating team. We are not a wound service and nothing here is medical advice. What this guide covers is why skin behaves differently after spinal cord injury, and the practical gaps in prevention that we see most often.

Why this happens, and why it is not about hygiene

Pressure injuries happen when sustained pressure on tissue over a bony prominence cuts off blood supply for long enough that the tissue dies. Shear and friction make it worse. Moisture makes it worse again.

After spinal cord injury, every single protective mechanism fails at once:

There is no warning signal. This is the fundamental difference. An intact person shifts position roughly every few minutes, mostly without noticing, because discomfort prompts it continuously. Remove sensation and that entire feedback loop disappears. Nothing hurts, so nothing prompts movement.

There is no spontaneous movement. Even where the prompt exists, the ability to act on it may not. A person who cannot push up, lean or roll cannot relieve pressure without help or equipment.

Blood flow below the injury is altered. Loss of sympathetic control changes vascular tone and reactive hyperaemia — the flush of blood that normally follows pressure relief. Tissue is less able to recover from a loading episode.

Muscle wastes away over exactly the wrong places. Atrophy of gluteal muscle reduces the padding over the ischial tuberosities and sacrum, so the same body weight is carried on a smaller area over harder bone. This is why risk rises over the years rather than falling: the padding keeps thinning.

Spasticity creates shear. Involuntary movement drags skin across a surface, which damages tissue at a lower pressure than compression alone.

Incontinence introduces moisture. Wet skin macerates and breaks down at lower pressures.

Nutrition is often marginal. Protein deficiency impairs healing and tissue resilience.

Note what is not on that list: carelessness. Pressure injuries after spinal cord injury are a predictable consequence of a body that cannot feel or move, not evidence that somebody failed to wash. People do get told, explicitly or by implication, that a pressure injury reflects poor self-care. It is a damaging and inaccurate framing and it stops people presenting early.

The surfaces nobody counts

Here is the gap we see most often, and it is the practical heart of this guide.

Prevention plans almost always address two surfaces: the bed and the wheelchair. A good mattress is specified. A good cushion is prescribed. Repositioning and weight shifts are written into the plan.

But a person with a spinal cord injury sits or lies on considerably more than two surfaces across a day. Account for all of them:

The wheelchair. Usually prescribed properly, with a cushion. Hours per day: many.

The bed. Usually prescribed properly, with a mattress. Hours per day: eight or more.

The shower commode or toileting chair. Hard plastic, often with a cut-out whose edges load the tissue directly either side of it, frequently wet, frequently a generic model rather than one fitted to the person. And the person may sit on it for an hour or more while completing a bowel programme.

This is, in our experience, the single most dangerous surface in most houses, and it is the one least likely to appear in a prevention plan or an assistive technology request. An hour of unrelieved loading on wet skin over the sacrum and ischia, on hard plastic with an aperture edge, every day or every second day, for years. If you are going to change one thing after reading this guide, look at the shower commode.

The car or vehicle seat. Often not pressure-relieving, and for anybody travelling distances in regional New South Wales, occupied for hours. The register shows injury rates in remote Australia running around three times those in major cities, which means long vehicle journeys to appointments are a routine part of life for a meaningful proportion of this population.

The recliner or lounge. The chair people transfer into to watch television in the evening, with no cushion, for three hours.

The shower chair, the physio bed, the hoist sling. A sling left under somebody after a transfer creates a fold of loaded fabric nobody can see.

The floor, the ground, the beach, the boat. Wherever an active person actually goes.

A prevention plan that addresses two of those eight is not a prevention plan. It is a partial one with a predictable failure point.

Sitting is the problem

A useful mental correction: most people think of pressure injuries as a bed problem, because that is where they occur in the general hospital population. After spinal cord injury the more important problem is sitting.

Sitting concentrates body weight onto a very small area — principally the ischial tuberosities, with the sacrum and coccyx loaded depending on posture. Interface pressures in sitting are substantially higher than in lying, over bone with less padding than it had five years earlier.

Which is why cushion prescription is not a minor accessory decision. It is one of the most consequential clinical decisions in the person’s long-term care.

A cushion is a prescription, not a product. The main categories behave differently:

• Air cell cushions offer excellent pressure redistribution and poor stability, and they require checking — an underinflated or punctured air cushion is worse than no cushion, and people ride on them for weeks without noticing.
• Foam is stable, cheap and requires replacing, because it compresses permanently and loses function long before it looks worn out.
• Gel and fluid offer good redistribution and are heavy.
• Hybrids combine approaches.

What should happen is a specialist seating assessment, with pressure mapping where available — which shows the actual interface pressures under the person on that cushion in that chair, and routinely surprises everybody involved.

What should also happen, and usually does not:

Review when the person changes. Weight change of a few kilograms meaningfully alters cushion fit. So does a change in posture, a new scoliosis, a surgical procedure, or a change in sitting tolerance.

Review when the cushion changes. Cushions wear out. Foam bottoms out. Air cells leak. Covers stretch and the stretch changes how the cushion works. A cushion in its fourth year is often doing a fraction of what it was prescribed to do.

Checking the cushion is set up correctly. Right way round, right inflation, cover not twisted, no towel or incontinence pad thrown over it. A folded towel on a pressure-redistributing cushion defeats a four-figure piece of equipment, and it happens constantly.

Weight shifts, and why they stop happening

The standard advice is to relieve pressure regularly while sitting — leaning forward, leaning to each side, or pushing up, for long enough to allow tissue reperfusion, repeated through the day. Specific regimens come from the treating team, and the detail of duration and frequency genuinely matters, because a shift too brief to restore blood flow achieves very little.

What is more useful here is why weight shifts fail in practice, because they do:

Shoulder pain. Push-up relief loads the shoulders hard, repeatedly, all day. In a population where shoulder overuse injury is close to universal over time, the thing people are told to do for their skin damages the joints they need for everything else. This is a real conflict and the answer is usually a powered tilt-in-space function rather than more push-ups — which is an equipment argument, not a willpower one.

Forgetting. Nothing prompts it. There is no discomfort. A person concentrating at work for three hours will not remember.

Equipment that cannot do it. A rigid manual chair without tilt requires the person to generate the relief themselves. Tilt-in-space and powered recline do it mechanically and far more reliably.

Fatigue. By evening, the capacity to keep doing this has gone.

The practical fixes are unglamorous: a phone alarm, a watch reminder, tilt function on the chair, and a culture among the people around the person where prompting is normal and not nagging.

Finding it, when you cannot feel it

Because there is no pain, detection depends entirely on somebody looking.

A daily skin check is not optional, and it must include the areas the person cannot see: sacrum, coccyx, ischial tuberosities, heels, ankles, hips, knees, elbows, the back of the head in people who spend time supine, under straps, under the catheter leg bag strap, between the toes, under the breast or abdominal fold.

How it gets done:

• A long-handled mirror, for people checking themselves.
• A phone camera — genuinely useful, both for seeing areas that are hard to reach and for comparing against last week.
• A worker, during personal care, with instruction on what to look for and somewhere to record it with a date.
• Checks at the same point in the routine every day, so it is not forgotten.

What to look for:

• Redness that does not fade when pressed. Non-blanching redness is already stage one damage.
• In darker skin, colour change is less reliable. Look and feel for changes in temperature, texture, firmness or boggy softness compared with surrounding skin, and for a purplish or darker discoloration. Pressure injuries are under-detected and detected later in people with darker skin, which is a known inequity and a reason to rely on touch as well as sight.
• A bruise-like purple or maroon patch. This may be a deep tissue injury — damage that started at the bone-muscle interface and is working its way outwards. It looks minor and is not. It can open into a deep cavity within days.
• A blister.
• Any break in the skin.
• Warmth, swelling, firmness or hardness.
• New or increased autonomic dysreflexia. In injuries at or above T6, a pressure injury is a listed trigger and dysreflexia is sometimes the first sign, discovered when somebody goes looking for the cause.
• New or increased spasticity, which can also signal tissue damage.

And the rule that matters more than any sign: a non-blanching red mark means the surface it came from must be unloaded immediately, not at the end of the shift, and not after the appointment next week. Stage one damage resolves if pressure is removed. Left loaded, it does not stay stage one.

What happens when it goes wrong

This section is blunt because the alternative is people not understanding what is at stake.

A deep pressure injury over the sacrum or ischium is not a wound that heals in a fortnight. The realistic trajectory of a stage III or IV injury includes:

• Weeks to months of complete offloading, which in practice frequently means bed rest. No sitting. Which means no wheelchair, no work, no driving, no going out.
• Deconditioning from that bed rest — loss of fitness, loss of sitting tolerance, loss of muscle, loss of independence, which then has to be rebuilt.
• Osteomyelitis — infection in the underlying bone — where the injury reaches it, requiring prolonged intravenous antibiotics.
• Surgical reconstruction, typically a myocutaneous flap, followed by a protocol of several weeks flat with a staged return to sitting.
• Flap failure and recurrence, which is common, because the underlying cause — a body that cannot feel or move, on the same surfaces — has not changed.
• Sepsis.
• Death, in around 7 to 8 per cent of people who develop a pressure injury, from related complications.

A single stage IV sacral pressure injury can cost somebody a year of their life. People lose jobs over this. Relationships strain. Hard-won independence is lost and sometimes not recovered.

Which is why the economics are so lopsided. A cushion review, a pressure-relieving shower commode, and funded repositioning hours cost a fraction of one admission with flap surgery — and the admission is the likelier outcome if the first three are not funded.

The prevention plan that actually covers it

If you are reviewing somebody’s arrangements, this is the checklist.

• [ ] Every surface across 24 hours identified — wheelchair, bed, shower commode, vehicle, lounge chair, sling, anywhere else — with a pressure strategy for each
• [ ] The shower commode specifically assessed, given the duration of bowel programmes on it
• [ ] Cushion prescribed by a specialist seating service, with pressure mapping where available
• [ ] Cushion age known, with a replacement cycle planned rather than reactive
• [ ] Cushion setup checked routinely — inflation, orientation, cover, nothing laid over it
• [ ] Mattress appropriate and its age known
• [ ] Tilt or recline function available where push-up relief is damaging shoulders
• [ ] Weight shift regimen set by the treating team, with a prompting method that works
• [ ] Daily skin check by a named person, recorded, including the areas the person cannot see
• [ ] Workers trained in what damage looks like, including in darker skin, including deep tissue injury
• [ ] An escalation rule: non-blanching redness means offload now and report today
• [ ] Continence management that keeps skin dry
• [ ] Nutrition reviewed, with protein adequacy checked
• [ ] Equipment reviewed after any weight change, posture change or surgery
• [ ] Transfer technique that does not drag — shear causes damage at lower pressures than compression
• [ ] Funded hours sufficient for repositioning and for an unrushed bowel programme
• [ ] Smoking addressed if relevant, given its effect on tissue perfusion and healing