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SCI Forum


Pressure ulcers can wreck your life! Preventing and managing skin problems after SCI


Presented by Deborah Crane, MD, MPH and Beth Hall, RN, CWS on January 10, 2012 at the University of Washington Medical Center, Seattle, WA.



Presentation time: 50 minutes. After watching, please complete our two-minute survey!


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Report: Preventing and Managing Skin Problems after SCI



Part 1: Risks and Causes

By Deborah Crane, MD, MPH, Assistant Professor, Department of Rehabilitation Medicine, UW Medicine

What are pressure ulcers?

The National Pressure Ulcer Advisory Panel defines a pressure ulcer as “a localized area of tissue necrosis that tends to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time." More simply put, tissue death results when the soft tissue gets squeezed between a firm spot and something external to your body. The area of damage is the pressure ulcer or sore.

How common are pressure ulcers?

It is challenging to pinpoint the precise likelihood of developing pressure ulcers. About one-third of people with new spinal cord injuries develop pressure ulcers during their initial hospitalization.

A study that used the National Model Systems SCI database reported new pressure ulcers among 7.9% of persons in the first year after SCI and 8.9% in the second year. A study of 219 veterans reported only 19.6 percent had no history of pressure ulcers. Another study of 800 veterans found that 62.4% of participants experienced pressure ulcers within one to 52 years after SCI. According to the 1998 National Spinal Cord Injury Statistical Center (NSCISC) Annual Report, 2971 of 4065 persons with SCI (73%) developed pressure ulcers when studied over a 20 year period.

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Why are we so concerned about pressure ulcers?

Pressure sores are a common cause of hospitalization
Once they go home after rehab, most folks with an SCI never want to be in a hospital again. But 39% of people rehospitalized in the first year after their SCI are admitted for pressure ulcers. And about one-third, or 34% of people with an SCI end up requiring three or more hospitalizations throughout the rest of their lifetime for treatment of pressure sores. If you want to stay out of the hospital, you definitely want to prevent a pressure sore.

Increased care needs—decreased independence
Having a pressure sore means you are likely to need more help with your personal care. You may go from being mostly or completely independent with your care to suddenly needing a lot of help and losing your independence if you get a pressure ulcer.

About 25% of the total lifetime cost of medical care for a person with SCI is related to pressure sores. Unfortunately, SCI is an expensive situation to be in, and we all want to reduce that cost as much as possible.

Personal costs
Perhaps most important of all, pressure sores can really change your life and have multiple negative consequences, including loss of income because you’re on bed rest and can’t go to work; increased care costs; the negative health effects of prolonged bed rest and inactivity; and loss of your usual activities and sources of life satisfaction. There’s a lot of personal suffering with dealing with a chronic sore, and it certainly can contribute to depression.

About 7–8% of deaths in the SCI population are related to a pressure sore. These deaths most likely result from sepsis, an infection that spreads throughout the body in the blood and tissues.  

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Risk factors

There are several factors that put a person with SCI at risk for pressure ulcers. Some are a direct consequence of the SCI, and some are not.

SCI-related risk factors

Other risk factors not related to your SCI

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This is the most common cause, and it’s important to be aware of how different amounts and duration of pressure can cause damage to skin. All of these conditions can be damaging:

Body tissues vary in their tolerance or their sensitivity to pressure. Skin is actually the most pressure-resistant compared to other body tissues. Muscle, because it is so metabolically active, can start to have problems more quickly than other tissues. That is why it’s possible for muscle underlying the skin to be damaged while the skin above it is still intact.

Dragging skin or body parts across a surface, as when transferring without lifting your backside off the surface, can damage your skin.

Abnormal or less than ideal positioning in your wheelchair, vehicle, or other equipment can increase pressure over specific bony areas.

Skin moisture and maceration
Skin that is exposed to moisture for extended periods can become macerated (softened and weakened) and vulnerable to breakdown. We worry most about exposure to urine and feces due to incontinence, but sweat can also be a problem.

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Mental status

Alcohol and recreational drugs


Low testosterone

Anemia and nutrition

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Part 2: Prevention, Skin Monitoring and Wound Management

By Beth Hall, RN, CWS, Wound Nurse Specialist, Harborview Medical Center

This part of the presentation is on prevention and management—what to look for, what to do, and what are the signs of early skin damage.

How do you know you have a problem?

Inspecting your skin


Areas of the body most at risk

Any areas with bony prominences are vulnerable to pressure sores, such as heels, knees, elbows, ischial tuberosities (sitting bones), sacrum (tail bone), iliac crest (lower back), shoulder blades, and the back of the head.

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What does it look like when a pressure ulcer is starting?

In pale or light complexions, look for skin that is:

In dark complexions, look for skin that is:


What do you do if you suspect damage?

If you don't correct the problem at the source, you might clear up one pressure ulcer, but it's just going to happen again.


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Stages of pressure ulcers

These official staging definitions come from the National Pressure Ulcer Advisory Panel (http://www.npuap.org/) .

Stage I



Usual healing time

If you follow the appropriate treatment, a Stage I pressure ulcer can be resolved in about three days. If you follow the treatments and still can't heal it, contact your healthcare provider. Early detection and appropriate treatment can prevent future problems.

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Stage II



Usual healing time: three days to three weeks.

Signs the wound is healing


Signs the wound is getting worse

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Stage III



Usual healing time: one to four months.

Signs the wound is getting worse


Signs the wound is healing

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Stage IV



Usual healing time: three months to two years.

Signs the wound is healing

As with Stage III, the wound starts to fill in, and tissue becomes pink.


Signs the wound is getting worse

It spreads into the surrounding tissue. There are signs of infection and probably evidence of bone or tendon damage.

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Unstageable pressure ulcer

It can't be staged, because if you can't see the base of a wound, you can't determine the extent of the damage.



Usual healing time: You cannot determine a healing time until the extent of the damage is known.

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Suspected deep tissue injury



Usual healing time: You cannot determine a healing time until the extent of the damage is known.

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Once a pressure ulcer has healed

Principles of wound care

1. Eliminate pressure.

2. Local wound care.

3. Monitor and measure

4. Application of outer dressing

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Nutrition and pressure ulcers

Don't forget!

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Part 3. Surgical interventions for pressure ulcers

By Deborah Crane, MD, MPH, Assistant Professor, Department of Rehabilitation Medicine, UW Medicine

Because of complications, failure rates, and other considerations, surgery is the option of last resort for treating pressure ulcers. It is not an easy or quick fix, and we hope that you never need to have this kind of surgery.

When is surgery considered?

Your physician or provider may start to think about getting a plastic surgeon to evaluate your ulcer in these situations:

What kind of surgery is available?

Surgery complications and failures

Who is the right candidate for flap surgery?

While many studies have examined this question, there has been little agreement on which factors—such as a patient’s age—predict whether flap surgery will be successful or not. All agree that smoking predicts a poor outcome or complication. In fact, smoking  is so universally recognized as contributing to a bad outcome that many surgeons will not consider doing the surgery if the patient is still smoking.

What happens after surgery?

This entire process usually takes place either in the hospital or a nursing facility. If all goes well, after about six weeks you will be able to go home and gradually return to some of your normal activities.

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  1. Montroy RE, Eltorai I. The surgical management of pressure ulcers. In Lin VW, Cardenas DD, Cutter NC, et al. Spinal Cord Medicine: Principles and Practice. New York, NY: Demos Medical Publishing, Inc; 2003:591-610.

  2. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Paralyzed Veterans of America; 2000:1-62.

  3. Priebe MM, Martin M, Wuermser LA, Castillo T, McFarlin J. The medical management of pressure ulcers. In Lin VW, Cardenas DD, Cutter NC, et al. Spinal Cord Medicine: Principles and Practice. New York, NY: Demos Medical Publishing, Inc; 2003:567-87.

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