Preventing iatrogenic facial pressure ulcers during spinal surgery: Prospective trial using a novel method and review of literature

Abstract

To assess the outcome of a novel method of preventing facial pressure ulcers in spinal surgery and a review of literature. A prospective trial using a novel method of facial protection using paraffin tulle gras dressing to cover bony prominences during spinal surgical procedures was performed. Patients were reviewed at 24 hours and 6 weeks. A telephone survey was also conducted post discharge. Over an 8‐month period, 12 patients (7F:5M, age 9‐72 years) underwent spine surgery for tumour stabilisation (n = 7), deformity correction (n = 4), and degenerative presentation (n = 1) with mean operative time of 472 minutes (range 150‐785 minutes) in prone position. All patients were managed by the same team using an agreed protocol. No pressure ulcers were noted in our study. One patient sustained minimal erythema, which resolved after 24 hours. All patients were satisfied with the care received. Facial pressure ulcers though much reduced are still common in spinal surgery. The common factors are the long duration of surgery, shear, friction, moisture, and intrinsic factors. Our strategy of an appropriate facial support and constant vigilance helped eliminate the incidence of iatrogenic facial ulcers in spinal surgery.

1. INTRODUCTION

A pressure injury is localised damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. ¹

The risk of developing iatrogenic facial pressure ulcers (PU) in spinal surgery is high due to the increased duration of surgery and pressure effects on the bony prominences. ² , ³ , ⁴ The incidence of intraoperatively acquired pressure ulcers ranges from 12% to 66%. ⁵ , ⁶ PU increase hospital length of stay and mortality (25%‐33%). ⁷ , ⁸ , ⁹ , ¹⁰

The development of PU is dependent on three factors—skin pressure over a bony prominence, extrinsic, and intrinsic factors. ³ Pressure effects are seen when a bony prominence is compressed on an external surface dependent on time and force. PU develop in stages from hyperemia, ischaemia, necrosis to ulceration. ¹¹ The National Pressure Ulcer Advisory Panel (NPUAP) has classified PU from Stage 1 to Stage 4 depending on their severity and other classifications based on types of pressure injury (NPUAP) (Table 1).

TABLE 1.

NPUAP/EPUAP pressure ulcer classification system category

Stage I	Non‐blanchable redness of intact skin
Stage II	Partial thickness skin loss or blister
Stage III	Full thickness skin loss (fat visible)
Stage IV	Full thickness tissue loss (muscle/bone visible)
Unstageable Pressure Injury	Obscured full thickness skin and tissue loss
Deep tissue Pressure Injury	Persistent non‐blanchable deep red, maroon or purple discoloration
Mucosal Membrane Pressure Injury

Extrinsic factors such as shear, friction, moisture, and type of material placed between the skin and support site are well known causes for PU. ¹² , ¹⁶ Intrinsic factors are usually related to age, medications (steroids), comorbidities (diabetes, ischaemic and circulatory), nutritional, smoking etc. ¹⁴ , ¹⁵

Many methods have been used to prevent its occurrence with mixed results. Our previous practice involved using a foam based cushion, but this was reviewed after a few incidents of PU were reported postoperatively from our Intensive Care Unit (ICU).

This study investigated the benefits of a novel method for head support during prone spine surgery using a paraffin tulle gras dressing to assess if it would prevent the incidence of iatrogenic facial pressure ulcers during medium to long spinal surgical procedures (>150 minutes).

2. METHOD AND PATIENTS

We performed an initial trial (three patients with operative times in excess of 600 minutes) with the addition of paraffin tulle gras laid over areas of facial prominence over a foam base cushion to reduce friction and shear forces. (Figures 1 and 2). The trial was then formally extended when no incidence of PU was noted to assess if results were replicable in a larger cohort over an 8‐month period.

FIGURE 1.

Anterior view of novel method using paraffin tulle gras on mannequin

FIGURE 2.

Lateral view of novel method using paraffin tulle gras on mannequin

Inclusion criteria were all patients undergoing spine surgery in prone position with expected operating time over 150 minutes. Exclusion criteria were patients with pre‐existing skin lesions and spinal procedures, which were less than two and a half hours of operating time.

Patients were informed preoperatively about this novel method and informed consent obtained. Board permission was not required as no major changes were made to current anaesthetic protocol and the dressing itself had no potential adverse impact on patients.

Data were collected prospectively for patient demographics, operative data, and postoperative outcomes. All patients underwent daily review postoperatively until discharge, and in a follow up clinic at 6 weeks. A follow‐up phone questionnaire was carried out with a set of seven questions to assess patient reported outcome measures (PROM) (Table 2). The primary outcome was the development of PU of at least Grade 2 by the third postoperative day.

TABLE 2.

Questions formally recorded during phone interview

Have you noticed any change in the appearance of your face in the first 3 d after the operation? Did you need any topical treatment for your facial skin complaints? Were you reviewed/assessed by a plastic surgeon for these problems? Are you still on any treatment for these problems? If yes—details? Do you think there are any persistent scars created by this problem? On a scale of 1 to 10 how severe would you consider the impact of these problems is on your daily life? Are you happy with the anaesthetic intervention and would you have it again?

3. RESULTS

A total of 12 patients were included in the study (5:7—M:F) with a mean age of 41.9 years (range 9‐72). The average duration of the procedure was 472 minutes (range 150‐785 minutes) in prone position. The procedures ranged from scoliosis correction (n = 4), degenerative conditions (n = 1) to complex tumour reconstructive surgery (n = 7). All patients were managed by the same team using an agreed protocol. No pressure ulcers were noted in our study. One patient sustained some erythema, which resolved after 24 hours. All patients were satisfied with the care received.

One patient with fixed flexion deformity of the neck developed erythema on her forehead, which lasted 1 day postoperatively. No patients needed any specialist intervention from Tissue Viability team/Plastic Surgical Team.

Phone questionnaires confirmed that all patients were fully satisfied with the intervention (12/12), needing no specialist input (12/12) and were happy to use the intervention again if needed (12/12). Eleven out of twelve patients noticed no facial changes; all patients needed no treatment for facial PU postoperatively with no scars from our intervention.

4. DISCUSSION AND REVIEW OF LITERATURE

The most common cause of PU occurring perioperatively during spinal surgery is due to the positioning of the patient during a lengthy procedure. ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁹ An intraoperative cause must be suspected when PU develop with 72 hours postoperatively as it may not reveal itself for that period. ⁶ , ²¹ While the most common facial areas for PU are the bony prominences, soft tissue structures such as the lips, tongue, and eyes are equally at risk. ²² , ²³ , ²⁴ , ²⁵ , ²⁶ Reduced blood flow at bony prominences occurs due to shearing forces and decreased muscle tone caused by anaesthetic effect (including paralysing the patient) and exacerbated by high interface friction pressures, occurring within the time period for most complex spine procedures. ²⁷ , ²⁸

Loss of position can occur and lack of clear visibility due to draping can reduce vigilance. Extrinsic risk factors are those variables that increase tissue susceptibility to sustain external pressure; they include temperature, friction/ shearing forces, and moisture. The use of warming blankets can through increased sweating and moisture create friction thus macerating the skin. ¹³ An intraoperative diastolic pressure below 60 mmHg and an external pressure above 32 mmHg can occlude capillaries and contribute to the development of PU.

Intrinsic factors that increase the risk of PU are older age, poor nutrition (albumin < 3 g/dl), diabetes, peripheral vascular disease, decreased mental status, lung disease, weight etc. The operative time has a huge bearing on the risk of developing PU with procedures more than two and a half hours at most risk. ⁵ , ²⁸ , ²⁹

Previous attempts at reducing PU have been directed at using various head rests and face masks made of foam‐cushion (including with parabolic shaped depressions), polyurethane, gel mattress, protected helmet systems, and a transparent operating table to facilitate intraoperative monitoring. ⁹ , ²⁸ , ³⁰ , ³¹ , ³² Some authors have advocated the use of the Mayfield clamp ³⁴ to reduce the incidence of PU; however, it has to be noted that side effects were seen with its use including epidural haematomas, air embolism, and skull fractures. ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷

Our study was initiated when we noted some pressure changes on the facial areas postoperatively. Prior to our new technique, we used a foam cushion‐based support, which had a limited size range meaning no flexibility to adjust its contour based on the size of individual patients. Our new technique involved the use of paraffin tulle gras dressing which is greasy, has low adherence and reduces friction and shear. This is important in surgical procedures where re‐positioning every 2 hours is not possible. ⁵

We also noted that movement of the face occurred when neuromonitoring stimulation is performed and during the course of long procedures this can be repeated many times causing shear forces on the face leading to PU. ³⁸ , ³⁹ No such incidents occurred with our new facial protection. Our facial protection is cheap and easily available and has been proven to eliminate the occurrence of PU.

The reduction in the incidence of iatrogenic facial PU should always begin with active identification of high‐risk patients, choosing the best support devices, frequent, and regular monitoring with close attention to blood and tissue perfusion pressures. ⁴ , ⁴⁰ Current guidance may also be found on the NHS Improvement website. ⁴²

In summary, this study demonstrates that facial protection using paraffin gauze dressing leads to favourable outcomes and prevents facial pressure ulcers during prolonged spine surgery in prone position.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

Haleem S, Mihai R, Rothenfluh DA, Reynolds J. Preventing iatrogenic facial pressure ulcers during spinal surgery: Prospective trial using a novel method and review of literature. Int Wound J. 2020;17:1391–1395. 10.1111/iwj.13402