Disclosures: Christopher White, MD: No financial relationships or conflicts of interest

Case Diagnosis: 74-year-old male with remote L2-4 fusion, T11 AIS D paraplegia from thoracic myelopathy recently post T11-12 laminectomies who developed osteodiscitis resulting in spinal instability, requiring unique spinal precautions.

Case Description or Program Description: At baseline, the patient was functioning at a modified independent level, including ambulation. After falling, he was admitted to a local hospital where he was diagnosed with MSSA bacteremia from suspected osteodiscitis. Following sedated MRI, the patient woke with new flaccid lower extremity paralysis and sensory level below the umbilicus. The MRI revealed “fish-mouthing” of the T11-T12 vertebrae with severe canal stenosis. Subsequent exam revealed T10 AIS A paraplegia. Head-of-bed positioning < 40 degrees exacerbated spinal instability and fishmouthing. Thus, recommendations were made for unique spinal precautions.

Setting: Veteran’s Affairs Hospital

Assessment/Results: Due to suspected spinal instability with supine positioning, head of bed was always maintained at >40 degrees, which contradicts most skin protection literature. This posed unique challenges, particularly for skin protection in the setting of neurogenic bowel and fecal incontinence. A colostomy was ultimately recommended. Surgical intervention was eventually completed in his hospital bed with the head of bed >40 degrees, a first for our surgical colleagues.

Discussion (relevance): Pressure injuries are a common cause of morbidity and mortality following spinal cord injury. It is often recommended patients avoid “sacral sitting” or sitting with head of bed elevated >30 degrees to prevent pressure injury. Common management strategies for preventing skin breakdown include pressure offloading with tilt functions or manual pressure relief, skin checks, and repositioning. Our case demonstrates a difficult scenario where the typical strategies were impossible. Patients with spinal cord injury who are unable to maintain skin precautions present a unique challenge requiring creative solutions.

Conclusions: We present a patient with unique spinal precautions contrary to standard recommendations, resulting in need for upright surgical positioning for colostomy to both prevent skin breakdown and lower morbidity/mortality.

Level of Evidence: Level IV

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/reeling-in-fish-mouthing-unique-challenges-in-preventing-skin-breakdown-in-patient-with-spinal-instability/