June, 1965 P H Y S I O T H E R A P Y Page 7 THE SURGICAL TREATMENT OF PRESSURE ULCERS IN THE PATIENT WITH SPINAL INJURIES By D R . J. A . E N G E L B R E C H T , m b , c h .,b ., f .c .s . (s .a .) P lastic Surgeon to the Cape P araplegic U n it, Conradie H ospital It was believed for m any years that the healing pow ers in paraplegic patients was not the sam e as that in norm al persons. This idea w as especially propagated by Charcot, who postulated that there were so called, trophic centra, in the spinal cord. Injuries to the spinal cord cause dam age to these trophic centra w ith resultant poor healing in these patients. By careful observation and a lso clinical com parison, it has been proved that the healing pow er in the paraplegic patient is n o different from that in a norm al person, provided no pressure is allow ed on the skin and subcutaneous tissue. On the other hand, it must be remembered that ven ou s congestion w ill interfere to a large extent with norm al healing and may itself cause ulceration as w e see for instance, in patients with varicose ulcers. These paralysed patients are far m ore liable to venous congestion in the paralysed limbs, because o f their abnorm al sym pathetic and parasym pa­ thetic vascular control. T his venous con gestion in the paralysed lim bs appears to be m ost severe during the first three m onths after injury, especially in cervical injuries. After that, the vascular tonu s im proves slow ly, and the venous congestion o f the skin dim inishes. The im portant factors in the prevention o f pressure ulcers, both in the routine m anagem ent and during the post-opera­ tive phase are therefore, regular turning o f the patient, to prevent pressure, and active physiotherapy from an early stage o f the paralysed lim bs to im prove the venous return. M ovements o f these lim bs, plus deep breathing are o f the greatest im portance in helping the venous return. Where pressure ulcers have developed it is im portant that they should be closed a s so o n as possible, because they are not only a constan t source o f infection, but are the cause o f a tremendous and continuou s loss o f proteins by the patient. This is one o f the reasons why these patients have great difficulty in m aintaining a norm al haem oglobin level. The presence o f these infected ulcers also has a very p oor psych o­ logical effect on the patients. It is often astonishing to see how the m ental state im proves after these ulcers have been closed. Where these ulcers have extended to the underlying bone, the chances that spontaneous and perm anent healing will occur is rem ote. This applies particularly to the tro­ chanteric and ischial regions, where although the ulcers often appear to be sm all on the surface, they are usually txea j.i *v_9 A t j a . S I -yv) l̂ Dun b