Spinal cord injury (SCI) is defined as any damage to the spinal cord resulting in partial or complete loss of motor, sensory, and autonomic function below the level of injury. Higher-level injuries, particularly cervical SCIs, lead to tetraplegia and profound immobility, severely limiting functional independence. Thoracic or lumbar SCIs typically result in paraplegia, with preserved upper limb function but substantial limitations in lower-body mobility [1]. SCI leads to complications that significantly impact quality of life (QoL), including respiratory dysfunction, neurogenic bowel and bladder, osteoporosis, pressure injuries (PIs), and alterations in metabolism that lead to changes in body composition such as sarcopenia and obesity [2–6]. Tetraplegia profoundly increases the risk of malnutrition due to reduced muscle mass, impaired gastrointestinal function, and greater metabolic alterations and paraplegia contributes to reduced physical activity and altered nutrient requirements [7]. Neurogenic obesity occurs due to low metabolic rate and total daily energy expenditure (TDEE) [8] and increases cardiometabolic risk [9]. Also, gut microbiome changes that occur in SCI contribute to chronic inflammation and metabolic disorders [10]. Early after SCI, weight loss may occur due to increased metabolic demand from trauma [11] or undernutrition driven by infections, dysphagia, hormonal changes, wounds, and psychological stress [12].

PIs are localized skin or tissue injury from pressure or shear [13] and, despite being preventable, 20–50% of acute SCI patients develop PIs in the hospital [14]. PI annual incidence in SCI patients ranges from 25.3% to 41.0% [15] and lifetime risk reaches 85.0–95.0% [16]. Malnutrition, which affects 86% of SCI patients with PIs [17, 18], is a major risk factor for PI severity and delayed healing [19]. PIs cause infections, impair rehab, reduce well-being, extend hospital stays, and raise mortality [20–22]. They impose high healthcare costs ($4,745/month) [23], along with indirect costs and caregiver burden [24]. PIs may represent 25% of SCI care costs, with treatment more expensive than prevention [25, 26].

This review explores PI prevention and treatment strategies across care settings, emphasizing the role of targeted nutritional interventions in SCI.

A multidisciplinary panel, including a wound care physician, urologist, physician nutrition specialist, two internal medicine specialists, and two physical medicine and rehabilitation physicians, met in July 2024 to address PI management in SCI patients in Italy. The group evaluated PI risk and reviewed prevention and treatment strategies, with a focus on identifying nutritional deficiencies and proposing dietary interventions to support wound healing. This review presents consensus-based recommendations (≥ 70% agreement). A narrative literature review was also conducted to support the discussions. Articles were selected based on their relevance following targeted searches in PubMed. The search strategy included combinations of the following keywords and Boolean operators: “spinal cord injury” AND “pressure injury” OR “pressure ulcer” OR “pressure sores”; “spinal cord injury” AND “risk factors” OR “mobility limitations” OR “skin integrity” OR “autonomic dysreflexia”; “spinal cord injury” AND “risk assessment” OR “risk assessment tools” OR “Braden Scale” OR “SCIPUS” OR “SCIPUS-A” OR “LPD Scale”; “spinal cord injuries” AND “nutrition assessment” OR “nutritional status”; “spinal cord injury” AND “change in body composition” OR “malnutrition” OR “undernutrition” OR “dietary supplements”; “spinal cord injury” AND “energy expenditure”; “anti-inflammatory diets”; “anti-inflammatory nutrients”; “Mediterranean diet” AND “inflammation”; “spinal cord injury” AND “gastrointestinal microbiome” OR dysbiosis; “spinal cord injury” AND “multidisciplinary”.

Effective management of SCI patients should prioritize early PI risk assessment, the timely implementation of preventive strategies (e.g., specialized pressure redistribution devices) and early detection [25]. Preventing PIs requires a lifelong commitment, emphasizing the need for continuous education for patients and structured training programs for healthcare professionals (HCPs) [26–28]. As growing evidence underscores the critical role of nutrition in wound healing, targeted dietary interventions might support the prevention of PIs and tissue repair while reducing complications [29].

Previously published data have categorized PI risk factors into intrinsic and extrinsic [30–32]. Building on this evidence and their clinical experience, the authors have drawn attention to the most relevant elements that increase vulnerability to PI development and delay wound healing (Table 1).

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Table 1. Risk Factors for PIs in SCI Patients

The authors have also emphasized the need for a collaborative approach between patients and the multidisciplinary team, including physical medicine and rehabilitation physicians, wound-care specialists, neurologists, internal medicine specialists, urologists, physician nutrition specialists, and nurses [33]. This model aims at improving prevention strategies and outcomes through shared decision-making. Also, access to relevant health information enhances adherence to preventive measures and supports effective self-care. Given patient variability, especially in acute phases, regular reassessment is needed. In community settings, where limited time and resources constrain HCPs to episodic contact, patients and their families are increasingly expected to manage their own care [34].

The authors reviewed the reliability of tools used to predict PI risk in SCI patients (Table 2 [31, 33, 35–39]).

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Table 2. Existing Evidence on the Use of Risk Assessment Tools for PI Prediction in SCI Populations

Four key themes have been identified regarding patient perceptions of PI risk and the communication of risk between nurse and patient in the home setting: 1) PI awareness; 2) importance of repositioning; 3) healthy eating; and 4) risk interpretation [40]. Accordingly, the authors stressed the need to educate HCPs in PI prevention, detection, and management, possibly through master’s degree programs in SCI-related PI care.

The authors underlined the importance of an assessment by wound-care expert physicians and/or nurses trained in wound care to classify the PI based on staging (Fig. 1) [41].

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Figure 1. Stages of PIs based on EPUAP classification. EPUAP: European Pressure Ulcer Advisory Panel; PIs: pressure injuries.

The importance of multidisciplinary pre- and postoperative care and patient education has been highlighted in prior research. This strategy is based on the collaboration between plastic surgeons, internal medicine specialists, and physical medicine and rehabilitation physicians [30]. Key clinical domains involved in the holistic management of patients with PIs, emphasizing a multidisciplinary approach, are outlined in Table 3 [30, 42–51].

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Table 3. Comprehensive Multidisciplinary Assessment Domains for Patients With Chronic PIs

Although precise nutrient needs for SCI patients remain unclear, high-protein oral supplements have been shown to reduce PI incidence by 25% in at-risk individuals. Energy, protein, arginine, glutamine, omega-3 fatty acids, and key micronutrients, such as vitamins A, B, C, zinc, and iron, support collagen synthesis, inflammation control, and tissue repair [52, 53]. Essential amino acids aid in nitrogen balance and promote fibroblast proliferation, angiogenesis, and immune function. Adequate hydration maintains skin integrity, cellular metabolism and blood flow to injured tissue, preventing further skin damage and delayed wound healing [52, 53]. Malnutrition compromises collagen formation and immune response, worsening PI outcomes [54, 55]. Chronic wounds, such as PIs, sustain prolonged inflammation, with low growth factor levels and microbial contamination. Hypermetabolism and a catabolic state further raise protein needs and TDEE [56]. In this context, the intake of protein sources highly digestable and containing essential aminoacids is crucial [57, 58].

Published data reports that TDEE ranges from 2,030 to 3,344 kcal/day in the acute SCI phase, and from 1,332 to 2,834 kcal/day in chronic SCI. TDEE is reduced by up to 54% in individuals with tetraplegia and around 20% in those with paraplegia [9, 59]. Despite generally high protein intake, SCI patients may lack essential amino acids, which are vital for protein synthesis and tissue repair, particularly important in the context of PIs [60, 61]. Moreover, PI development rapidly depletes protein reserves, mainly skeletal muscle, accelerating malnutrition [62]. Accordingly, to identify patients at nutritional risk, the Spinal Nutrition Screening Tool (SNST), a validated, SCI-specific screening instrument, assesses skin integrity alongside several SCI-related and general clinical factors. These include age, weight history, appetite, injury level, comorbidities (e.g., need for artificial ventilation or nutrition), use of supplements, modified-texture diets, and the individual’s ability to eat. Each item is scored from 0 to 5, and the total score indicates the malnutrition risk category: 0–10 = low risk, 11–15 = moderate risk, and > 15 = high risk [63].

Guidelines recommend in SCI patients without PIs or infection an intake of 0.8–1.0 g/kg/day of protein to maintain protein status [62] and limiting saturated fat to 5–6% of total energy intake [64]. Carbohydrates should constitute 45–65% of daily energy intake, preferably from complex, fiber-rich, low-glycemic sources. A fiber intake of 25–30 g/day is advised to support metabolism and bowel function, and prevent neurogenic bowel dysfunction [62]. Although guidelines exist [9, 64, 65], there is an urgent need for innovative nutrition protocols tailored to SCI patients at risk of or presenting with PIs [66].

Tailored nutrition is essential for preventing PIs and promoting wound healing and should reflect specific clinical needs, such as metabolic syndrome or post-surgical recovery. Annual assessments and education by registered dietitians should be routine. Supplements may support outcomes but must follow individualized plans based on comprehensive evaluations addressing inflammation, oxidative stress, and immunity.

Diets should balance macronutrients to meet reduced TDEE and prioritize nutrient-dense, low-energy foods [67]. Given SCI-related immune dysfunction and inflammation, and comorbidities (e.g., diabetes and hypertension) [68], nutrition should aim to reduce advanced glycation end products (AGEs), which promote inflammation [69]. Although not SCI-specific, AGEs have been linked to degenerative cervical myelopathy [70]. Foods rich in melatonin or L-tryptophan (e.g., potatoes and chickpeas) possess anti-inflammatory properties and should be included [71, 72]. L-tryptophan aids serotonin and melatonin production and generates anti-inflammatory metabolites, such as indole-3-propionic acid via gut microbiota metabolism [73]. Similarly, L-arginine supports endothelial function, cardiovascular health, wound healing, and reduces inflammation [74].

Recent studies link intestinal dysbiosis, in particular bacterial lipopolysaccharides (LPS), to SCI-related gastrointestinal dysfunctions, systemic low-grade inflammation, obesity, insulin resistance, diabetes, and cardiovascular disease [75, 76]. In SCI, LPS translocation worsens inflammation [77, 78], making intestinal barrier integrity crucial for preventing immune dysregulation and systemic complications [79]. Indeed, gut health and immunity are closely interconnected, and a balanced gut microbiome supports the production of short-chain fatty acids (SCFAs), which exert anti-inflammatory effects and regulate insulin [80]. Reduced microbial diversity, common in SCI, increases susceptibility to infections, such as Clostridium difficile [81] and multidrug-resistant Staphylococcus aureus (MRSA) [82]. Enhancing microbial diversity and SCFA levels involves greater intake of fruits, vegetables, fish, and dietary fibers, such as pectins, inulin and resistant starches [77, 83, 84]. Melatonin has also been shown to correct SCI-induced microbiota imbalances [85]. Specific strains, such as Lactobacillus and Bifidobacterium produce neuroactive compounds, such as gamma-aminobutyric acid (GABA). Those molecules influence both central and peripheral nervous systems and potentially reduce anxiety and depression symptoms [86].

The authors emphasized the importance of dietary modifications to harness the nutraceutical properties of food. Anti-inflammatory diets prioritize foods known to reduce chronic low-grade inflammation, a key driver of many non-communicable diseases. These dietary patterns emphasize fruits, vegetables, whole grains, legumes, nuts, seeds, olive oil, herbs and spices, and sources of omega-3 fatty acids, such as fish. Conversely, they limit red and processed meat, refined carbohydrates, added sugars and saturated fats, which are linked to chronic low-grade inflammation [87]. Such diets are also rich in polyphenols, antioxidants, vitamins, minerals, fiber, and healthy fats, all of which modulate inflammatory pathways, by lowering pro-inflammatory cytokines and oxidative stress. Evidence suggests that anti-inflammatory diets, including the Mediterranean diet, can help reduce inflammation-related risk across a range of conditions, from obesity to cancer and cognitive decline, by improving metabolic health, supporting gut microbiota, and dampening the molecular signals that sustain chronic inflammation [88].

Studies show that olive oil-based diets improve PI healing by reducing inflammation, oxidative stress, and enhancing collagen synthesis [89]. Anti-inflammatory diets have proven beneficial for SCI patients [90].

An optimal SCI diet should: 1) reduce inflammation and oxidative stress, 2) enhance immunity, 3) support gut microbiota, and 4) limit AGEs [69, 91]. Key features of such a diet include: 1) high omega-3 content [92], 2) low omega-6/omega-3 ratio [93], 3) high intake of polyphenols and antioxidants from herbs, fruits, and vegetables [94], 4) low glycemic load [95], and 5) minimal ultra-processed foods [96]. While direct links with SCI are unconfirmed, AGEs trigger oxidative stress and inflammation, impair endothelial function and angiogenesis, common issues in chronic illness [97]. Both food content and cooking methods affect AGE levels [98]. Strategies to reduce dietary AGEs include: 1) avoiding high-AGE foods, 2) using cooking methods that limit AGE formation, and 3) reducing intake of AGE-promoting ingredients, such as fructose. While foods rich in AGEs are aged and high-fat cheeses and dry-processed carbohydrates (e.g., crackers), AGE content increases depending on the cooking method (Table 4) [98, 99].

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Table 4. Examples to Better Understand How the Cooking Method Can Be Decisive

Anti-inflammatory compounds, such as quercetin, resveratrol, curcumin, and catechin, can help counteract AGE accumulation [100].

Hydration is essential for wound healing and skin health. Recommended fluid intake is 1 mL per kcal of energy needs plus 500 mL, or 40 mL/kg of body mass plus 500 mL [101]. Additional fluids are needed for those with draining wounds or excessive sweating. Immunonutrition formulas, typically including arginine, glutamine, omega-3s, vitamins, and trace minerals, have been associated with reduced infections and inflammation and improved gut health and wound healing [102]. These dietary principles form the foundation of nutritional strategies for SCI patients with or at risk for PIs (Table 5).

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Table 5. Key Dietary Components to Improve Immune Function and Gut Health

Patient education on precise dietary choices is essential and should be viewed as part of standard medical care. The proposed dietary plan is based on Mediterranean diet, which is consistently showing beneficial effects on chronic conditions [103], and targets an 81-kg tetraplegic patient with no major comorbidities (Tables 6–11). The plan assumes an energy intake of ∼20 kcal/kg body weight and includes 2 L of calcium-rich water (≥ 300 mg/L). Key points include: 1) sugar intake only from whole foods; 2) optimal calcium intake, excluding water contribution; 3) adequate intake of vitamins, minerals, and amino acids; and 4) suboptimal resveratrol levels, which require supplementation (Fig. 2).

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Table 6. Breakfast With Whole Oat Porridge With Berries, Flaxseeds, Kefir, and Almonds

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Table 7. Snack With Pear, Almonds, and Green Tea

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Table 8. Lunch With Whole Wheat Pasta With Chickpeas, Artichokes, Red Onion, Chicory; Steamed or Boiled Chicken Breast; Salad of Fresh Spinach, Red Onion, Avocado, Olive Oil, Turmeric, Ginger, and Black Pepper

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Table 9. Snack With Greek Yogurt With Chia Seeds and Green Tea

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Table 10. Dinner With Baked Salmon Fillet With Broccoli, Red Onion, Whole-Grain Bread, Olive Oil, Turmeric, Ginger, and Black Pepper

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Table 11. Total Daily Intakes

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Figure 2. Characteristics of an anti-inflammatory diet that promotes gut health and limits the amount of advanced glycation end products.

Effective PI management includes enhancing psychosocial support, ensuring complete pressure relief, optimizing support surfaces and wheelchair seating systems, and providing adequate nutrition. In addition, reducing wound bioburden, eradicating infections, and, when necessary, performing surgical interventions followed by appropriate postoperative care all form essential components of the overall management strategy [104].

In the acute setting, verifying functional outcomes and using pressure redistribution devices are essential [104]. Physical activity helps prevent muscle atrophy, PIs, obesity, inactivity, and bone loss [105]. Patient weight should be assessed to ensure devices fit properly, as standard models may not suit individuals with obesity. For positioning and pressure relief [106], repositioning is advised every 2–4 h with support from nurses or therapists. Wheelchair users should shift weight for at least 30 s every 15 min and reposition hourly [13]. Nutritional support within 72 h is standard for trauma patients. Ongoing clinical and instrumental assessments are needed during acute and post-acute phases, with interventions tailored to high-risk individuals [59]. At discharge, nutrition counseling and assessing awareness of the role of diet in PI prevention and healing are strongly recommended.

In the chronic setting, PI prevention strategies mirror those in acute and post-acute phases and include daily skin checks for early detection, minimizing risk factors, and maintaining a balanced diet with nutritional counseling [107]. The authors emphasized the importance of educating patients and caregivers on PI risk factors and the role of nutrition in skin integrity and healing. To simplify dietary guidance, the authors introduced a Food Suitability Map that uses color-coding to classify foods based on nutritional value, drawing from international literature and databases. Foods are categorized by intake frequency within an anti-inflammatory Mediterranean diet [88, 103, 108]. Foods classified as “green” are those for daily use, with high therapeutic value. Foods classified as “yellow” are those for moderate weekly use with limited benefits. Foods classified as “orange” are those for occasional weekly use and display minimal benefit or mild risk. Foods classified as “red” are those for rare intake or to be avoided, due to potential harm and limited value (Fig. 3).

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Figure 3. A traffic light food map for SCI patients with PIs. PIs: pressure injuries; SCI: spinal cord injury.

Additional factors, such as bowel and sphincter function, colostomy presence, diabetes, QoL, physical activity, and eating habits, should be evaluated, with a 1-month follow-up recommended.

A food diary is essential for SCI patients to track intake, support metabolic health, PI prevention, and adherence to personalized plans. As biomarkers provide limited insight due to physiological variability and cannot guide dietary change [109], direct food tracking remains the most practical method. The authors advocate for a food diary as an interactive tool involving patients and caregivers, enhanced by the Food Suitability Map. This integration helps identify dietary patterns and necessary modifications. Core features of an effective food diary are listed in Table 12, and the diary templates (Figs 4 and 5) align with the Nutritional Therapeutic Plan. Color-coded entries reflect prescribed meals and guide appropriate substitutions based on the Suitability Map. A sample entry is shown in Figure 5.

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Table 12. Key Features of a Food Diary for Spinal Cord Injury Patients

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Figure 4. Template of a food diary for recording consumption according to the prescribed meal plan for breakfast.

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Figure 5. Example of how a food diary could look after patient interaction.

The authors highlighted the need for professional figures in this setting, as certified specialists in SCI management are often lacking. To address this, the authors suggested periodic follow-ups and specialized training programs to enable HCPs to provide optimal care. The recommendations outlined for other care settings should also be applied in this context.

A concerning statistic regards hospital readmissions of chronic SCI, 40% of cases of which are due to PIs. The authors emphasized the need for effective community-level handovers, as spinal units alone cannot meet growing care demands. A structured network between hospitals and local HCPs, based on clear communication, defined roles, and coordinated actions, is crucial for ensuring care continuity. In PI surgery, nutritional interventions should be initiated not only postoperatively [110], but also preoperatively as part of a “prehabilitation” strategy. The authors support incorporating dietary measures into a tailored Enhanced Recovery After Surgery (ERAS) protocol, encompassing pre-, intra-, and postoperative phases to improve recovery, prevent complications, and optimize outcomes [104]. Before PI-related surgery, patients should undergo gastroenterological evaluation to assess colostomy needs. Rehabilitation specialists and occupational therapists (OTs) evaluate home care, seating, pressure relief, and bladder function. Dietitians help tailor nutrition plans to support wound healing and muscle maintenance. OTs also assess skin integrity, identify risks, recommend preventive strategies, evaluate the adequacy of pressure-relief devices, and guide patients and caregivers on skin inspection. Psychologists support emotional well-being and adherence to care plans, enhancing motivation, coping, and long-term self-management [13, 111].

Managing patients with SCIs requires a multidisciplinary approach, with nutrition playing a key role in preventing and treating PIs. Individualized dietary strategies are essential to address SCI-related metabolic and inflammatory issues. Supporting gut health with fiber, probiotics, and anti-inflammatory foods alongside the intake of micronutrients (e.g., vitamins A, C, zinc, iron) and adequate hydration can promote wound healing and lower PI risk, helping maintain immune function and reduce inflammation. Personalized dietary plans, guided by qualified dietitians, should meet energy and nutrient needs in SCI. Tools such as food diaries and dietary maps can enhance education, adherence, and informed decision-making. Implementing evidence-based nutrition protocols can improve outcomes, reduce costs, and enhance QoL for SCI patients. Future research should refine dietary interventions, evaluate nutraceuticals, and assess the long-term impact of nutrition on PI prevention and healing.

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