Retrospective cohort study using MIMIC-IV database. We identified 2,985 neuropathy patients through diagnostic codes (polyneuropathy, diabetic neuropathy, autonomic neuropathy, mononeuropathy) and indirect markers (diabetic foot ulcers, amputations with diabetes). Patients were propensity-score matched with 2,652 controls without neuropathy, balancing demographics, comorbidities, and illness severity. Primary outcome was ICU-acquired pressure injury incidence. Neuropathy subtypes analyzed: unspecified polyneuropathy (n=1,370), diabetic neuropathy (n=1,228), autonomic neuropathy (n=288), mononeuropathy (n=222), inflammatory neuropathy (n=114), hereditary neuropathy (n=85).

Neuropathy patients demonstrated 2.74-fold higher pressure injury risk (9.6% vs 3.5%, p<0.0001). Absolute risk difference of 6.1 percentage points represents substantial clinical burden affecting 287 versus 93 patients. Injuries developed despite significantly shorter ICU stays in neuropathy patients (mean 7.5 vs 12.6 days for injured patients), indicating accelerated injury timeline and increased per-day vulnerability. The "neuropathy paradox" was confirmed: patients with reduced protective sensation had higher, not lower, injury rates across all neuropathy subtypes.

Peripheral neuropathy is a major, underrecognized independent risk factor for ICU-acquired pressure injuries. Combined sensory loss, impaired pain-mediated repositioning, and autonomic dysfunction heighten vulnerability, while standard neurological exams inadequately capture this risk. Neuropathy should be promptly identified as requiring intensified prevention strategies, including advanced pressure redistribution, accelerated repositioning schedules, and targeted skin monitoring of insensate areas.