Bedsore over Sacrum (Lower Back)

Bedsore Development

Bedsores, or pressure ulcers, can develop when a person remains in the same position for an extended period. The location of the bedsore depends on the patient’s body position:

• Prolonged seated position can lead to ischium (seat bone) bedsores.
• Prolonged lying-down position can cause sacrum (lower back) bedsores.
• Prolonged side position can result in trochanter (side bone/hip) bedsores.

Other common areas for bedsores include the heel, elbow, malleolus (ankle), knee, scapula (shoulder blade) , and occiput (back of the head).

Development of Sacral Bed Sores

Sacral bed sores, or lower back bedsores, typically occur in patients who are very sick and unable to move due to primary ailments such as paralysis, trauma, fractures, old age, etc. Patients admitted to the hospital for extended periods, particularly in the ICU or on ventilators, are also prone to developing sacral bedsores. The prolonged pressure over the lower back region makes these patients susceptible to this condition.

Categories of Sacral Bed Sores

Bedsores are categorized based on the extent of damage they have caused:

• Category I: Generalized redness over the pressure areas.
• Category II: Partial loss of superficial skin, similar to an injury from rubbing against an object.
• Category III and IV: Full-thickness loss of skin and muscle in Category III and exposure of bones in Category IV.

For bedsores at any stage, relatives or attendants are advised to consult a plastic surgeon immediately to prevent further progression.

Treatment at Kayakriti

For Categories I and II:

Patients with Category I or II sacral bed sores may not require admission if other factors and comorbidities are well controlled. They are educated about wound management, and specific dressings are advised. Follow-up is typically scheduled weekly initially, and later, once a month for three months after complete healing.

For Categories III and IV:

Patients with Category III or IV sacral bed sores require hospital admission. A comprehensive evaluation of their nutritional status and surgical fitness is conducted. After admission and after ensuring that the patient is vitally stable and medically cleared for surgery, surgical treatment is planned.

• Single-Stage Surgery: In some cases, a single-stage surgery is performed, which involves proper debridement to remove the entire bedsore, excising the infected portion of the sacral bone, and closing the resultant defect using a flap from the surrounding area.
• Two-Staged Surgery: Two-staged surgery may be necessary in certain cases, including when the wound is severely infected and needs further debridement or when the defect is too large to be closed in one stage. The patient may also be too ill to undergo immediate flap coverage. In the first stage, debridement of the sore is performed, and Negative Pressure Wound Therapy (VAC) is applied for 5-7 days. After about a week, the VAC is removed. If there are no signs of active infection, and the patient’s condition has improved, a flap cover surgery is planned for the second stage.
• In the second surgery, wound closure is typically achieved with a local flap. This involves using the skin and soft tissue from the surrounding normal area, such as the gluteus maximus muscle flap with the overlying skin, rotation flap, and V to Y advancement flap, among others.

In rare cases where the defect is too large, microvascular free flap surgery may be necessary. In this procedure, a flap is harvested from another part of the body and transferred to the sacral area. Microsurgical techniques are used to connect the vessels of the flap to the vessels of the sacral region.

Recovery After Surgery

• The patient is nursed in the prone position,
• An air mattress is used,
• Proper Hygiene has to be maintained,
• Foley’s catheterization is done and
• Flap is being monitored regularly for any color changes, or any infection.
• The patient is kept on a soft diet for a few days, to decrease the frequency of stools.
• Dressing is done every alternate day.
• The patient is kept in the hospital for at least 2 weeks.
• Suction is removed once the amount is less than 10-15 ml in 24 hours.
• Sutures are removed after 2 weeks.
• Once the flap is settled and the patient is vitally stable, discharge is planned.

Patients are educated about home care, including the use of an air mattress, hygiene, and regular side-to-side turning. Follow-up visits are scheduled after one week and later once or twice a month for the next three months.