Assessing patterns of pressure injury development in patients with Spinal Cord Injury (SCI) with Lower Motor Neuron (LMN) and Upper Motor Neuron (UMN) lesions: A Case Report
1Morgan M, 1Catania Q, 2Martin R, 3Dean J
1Kennedy Krieger Institute, Baltimore, MD, 21230; 2Kennedy Krieger Institute; The Johns Hopkins University School of Medicine, Baltimore, MD, USA; 3Kennedy Krieger Institute; Johns Hopkins Department of Rehabilitation, Baltimore, MD, 21230
Introduction: Neurologic impairments after spinal cord injury (SCI) are classified according to the last intact root above the injured portion of the cord and completeness of lesion; this divides patients into either Upper Motor Neuron (UMN) or Lower Motor Neuron (LMN) presentations.1 Patients with SCI, regardless of UMN or LMN lesions, share the following risk factors: skin quality, mobility, level of spinal lesion, existing/previous pressure injuries, and independence in pressure injury management.2 It was estimated that up to 95% of adults with a SCI will develop at least one pressure injury in their lifetime.2 Yet research comparing characteristics of spinal lesions and how they affect the risk of developing pressure injuries are rare.3,4 This paper aims to further delve into patients with UMN versus LMN to determine if one type of lesion increases the risk of developing pressure injuries. It will further explore whether differences between the lesion characteristics can predict severity of the pressure injuries. We hypothesize that patients with LMN lesions are more susceptible to developing more serious pressure injuries compared to patients with UMN lesions, needing more intensive treatment interventions for wound closure.
Case Presentation: This is a 4 year retrospective case study comparing history and/or presence of pressure injuries in patients with UMN and LMN lesions who had a bout of care at an outpatient rehabilitation center from 2013-2016. To determine sample size, all LMN patients were selected while UMN patients were randomized, using random pattern generation, and an equal sample size to the LMN group was selected. Those with LMN lesions were defined as receiving no antispasticity medication and has a score of 0 on the Modified Ashworth Scale (MAS) while and those with UMN lesions were defined as any number greater than 0 on MAS, with or without pharmacological management, and DTR/Babinski if present in the doctor’s note. Once in their respective categories, outcome measures collected included presence of pressure injury upon admission, history of pressure injury, and need for intensive treatment interventions for wound closure.
Therapeutic Focus and Assessment: Determining appropriate risk factors specific to SCI can assist with positional recommendations, appropriate patient education, and effective pharmacological interventions to decrease risk of developing pressure injuries.
Results: Approximately equal amounts of patients from both LMN and UMN groups presented with history of pressure ulcer development. However, those with LMN tend to more severe pressure injuries, needing to be treated with skin flap procedures for wound closure.
Discussion: This case study identify that hypertonia and hypotonia could be SCI specific risk factors for development of pressure injuries as they have a direct impact a patient's independence with activity of daily living, transfers, and mobility. Risk factors specific to SCI should continue to be further studied to provide early detection and more specific risk assessment tools for pressure injuries.2 A better assessment tool can lead to decrease prevalence of pressure ulcers in patients with SCI, leading to better quality of life and community integration.
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