Dysphagia
Considerations in
SCI/Surgical Intervention
At Risk Population
Incidences of transient dysphagia range from 35-50% peri-op. in
millennium studies.
About 10% may continue to have dysphagia at long-term
Females
Age >60 years
Undergoing multilevel surgery
Pre-existing swallowing dysfunction are especially at risk
Study
Fogel, G. R., and McDonnell, M. F.(2005)Surgical
treatment of dysphagia after anterior cervical
interbody fusion. Spine J, 5(2): 140-4.
Surgical Treatment of Dysphagia After
ACIF
Fogel and McDonnell (2005)
Hypothesized: removal of the anterior cervical plate would release adhesions of
the esophagus to prevertebral fascia and anterior C-spine.
Pre-op 31 patients: 15 had moderate dysphagia, 16 had severe dysphagia
Post-op at 1, 6, 12 months:
◦ 17 no dysphagia, 10 mild dysphagia associated with specific foods, 3
moderate dysphagia with solids, 1 persistent severe dysphagia with solids &
liquids
Surgical treatment of dysphagia is a reasonable option given dissatisfaction prior
to treatment.
Loose Anterior Fixation Plate Screw
Possible Complications from ACIF/ACDF
Hematoma – collection of blood from vascular
damage forms a mass, compression of pharynx,
cervical esophagus, obstructing laryngeal inlet
Edema – decreased pharyngeal wall movement,
impaired UES opening, incomplete epiglottic
inversion, and vallecular, pyriform sinus, and
posterior pharyngeal wall stasis
Possible Complications (cont’d)
Infection – Bacterial contamination or
inadvertent perforation of pharynx producing
necrosis and spillage from digestive tract
Denervation – Pharyngeal plexus comprised of
branches of the glossopharyngeal and vagus
nerves
Dysphagia and SCI/Surgery
Anatomy of at-risk structures:
◦glossopharyngeal and hypoglossal (impaired lingual
propulsion) nerves C3 or above
◦superior laryngeal nerve at C3-C4 (absent
pharyngeal swallow)
◦ Vagus nerve and recurrent laryngeal nerve at C6 or
below
◦Vagal input innervates upper esophageal region
Prevertebral Soft Tissue Edema
Kang et al. 2016 Prospective Study
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC510
2869/
Highest surgery level at C3 and C4 showed more
abnormal VFSS results: significantly increased soft
tissue thickness and decreased maximal UES opening
distance.
Post-op Dysphagia Symptoms
Symptoms reported:
◦ Odynophagia
◦ Dysphagia with saliva (difficulty managing oral secretions)
◦ Heartburn
◦ Coughing or choking with swallowing
◦ Regurgitation
◦ Feeling of blockage
◦ Frequent or delayed throat clearing
◦ Wet voice quality
◦ Vocal hoarseness
Dysphagia Due to
Cervical Spine Surgery
STUDY BY WELSH ET AL., OTORHINOLARYNGOLOGY JOURNAL; 1987.
Findings
Persistence of dysphagia symptoms >48 hours should alert physician
to possible regional complications
5 patients studied demonstrated improved swallowing function
ranging 8-15 days.
Superimposed febrile illness strongly implies infection, warranting
management
Caveats for infection following bone mass injection
◦ Injections at C6 and above are at higher risk for pharyngeal
perforation and contamination
◦ Relatively lateral position of pharyngeal wall
Disorders of Social
Cognition
EXCERPTS FROM MCDONALD ET AL. TEXT - CHAPTER 5
Disorders of Social Cognition
Attend to, recognize, interpret interpersonal cues
Help understand and predict behaviors
Share experiences and effectively communicate
Damage to orbito-ventral and medial frontal lobes
(Contrast to non-social cognition – dorsal areas of
lateral and medial prefrontal cortex)
Functions of the orbitofrontal cortex
http://www.oxcns.org/papers/357_Rolls04.pdf
Secondary Effects
Wallerian degeneration: deterioration of downstream
structures that become disconnected to structures at
lesion sites.
40-50% suffer expansion of initial contusions during
acute phase (Change et al., 2006)
DAI to brainstem – increased likelihood of impaired
social cognition
Deficits in Social Cognition
Emotional processing: emotional perception
and empathy
Mental judgements: infer intentions and beliefs
of others and see other POV; theory of mind
(ToM; Baron-Cohen et al., 1994)
Predict behavior of others
Static Vs. Dynamic Facial Expressions
Babbage et al., 2011 in a meta-analysis of 296 people with
TBI from 13 studies
Up to 39% of people with severe TBI had difficulty
recognizing static facial expressions and their emotional
associates.
Dynamic is yet more difficult – ever changing
Increased processing demand and mental flexibility
Vocal Perception
Recognizing vocal emotions
Deficits in recognition of facial expressions and vocal recognition can
co-occur or be independent of each other
Affected by slowed processing
Fear, disgust, sadness, and anger are less perceptible by patients
after TBI
Limbic structures and ventromedial frontal lobes rapidly detect
ambiguous events that have emotional context.
Amygdala – detects fear, sadness, anger; detects danger
Empathy
60-70% lack empathy as compared to 30% matched
adult controls. (de Sousa et al., 2012)
50% self-reported lack of empathy as compared to
18% controls.
Significant relationship between self-reported lack of
empathy and impaired emotional mimicry (imitation)
to negative facial expressions (de Sousa et al., 2010).
Empathy
Mimicry may have more relation to our empathetic
response to others than it does to emotional perception.
Self-awareness and self-regulation are important in
empathic process to recognize self from others (Decety &
Meyer, 2008).
Pedantic – Emphasis on formalities; points out corrections
in unimportant details; perfectionistic, meticulous,
fastidious
Disorders of Emotional Regulation
Disorders of Control or Drive are common after TBI
Commonly associated with executive skills
impairment
Important in managing emotional behavior and
decision making.
Disorders of Control
•Impulsivity
•Disinhibition (recall inhibitory and interference control)
•Inappropriate levels of self-disclosure
•Irritability
•Poor frustration tolerance
•Emotional lability
•Aggression
•Childlike affect
•Sexual disinhibition
Disorders of Drive
◦Apathy/Aspontaneity (medial & dorsal frontal lobes
connected to thalamus and reticular formation)
◦Egocentrism/Self-focused
◦Lack of interest in others/Indifference
◦Poor mental flexibility
◦ Adynamia – a rigid, uncompromising, inflexible thinking “black &
white”
Indifference
Decreased responsivity to others or environmental events
◦ adversely impacts a person’s emotional experience and complex
decision making.
A patient with an orbitofrontal lesion, intact memory and aboveaverage intelligence, exhibited poor social conduct.
Sociopathy – associated with damage to prefrontal cortex
consequently showed impaired activation of somatosensory system
(postfrontal cortex) necessary “to understand the implications of
poor social decisions”. (Damasio et al., 1990).
Social Cognition
These skills are critical for successful
interpersonal interactions.
Social Dysfunction in
Children & Adolescents
Social Skills
Children tend to rate social skills highest in
priority unlike their parents.
Reports estimate 10% of children are affected
by social dysfunction
Higher risk in TBI, 50%
Social Skills
Disruptions in development may cause
◦Psychological distress
◦Poor self-esteem
◦Feel different
◦Fatigue – poor motivation and endurance
◦Social anxiety
◦Social Isolation/Withdrawal
Factors Impacting Social Skills
Important for social function: biological models,
environment & experience
Overprotective parents or parental restrictions may limit
social opportunities.
TBI can result in physical, cognitive, communicative,
behavioral problems, and poor academic skills. (Anderson et
al., 2009)
Social Competence
Achieve personal goals in social settings while
maintaining positive relationships
Social Interaction
Modify social actions/reactions between
persons or groups
Social Adjustment
Adapt to changes or demands in a social
environment
Poor Social Outcomes
Poor social skills increase risk for delinquent, criminal
behavior, aggression, violence, disorders of conduct,
bullying, or sexual offenses
35% of incarcerated juveniles had TBI (Kenny & Jennings,
2007)
87% of adult prisoners had TBI (Butler et al., 2003)
Maternal attachment and parent-child interactions
contribute to long term social outcomes.
Social Skills Development
Infancy begins recognition of emotion in faces and in voice
Adolescent brain undergoes significant neurostructural changes
• Decreased gray matter volume and increased white matter density in
frontal and parietal lobes (Casey et al., 2005)
SS mediated by social-affective and cognitive-executive processes
(Yeates et al., 2007)
Lower SES associated with poor adjustment and peer misconduct
(Bulotsky-Shearer et al., 2008)
This population is at a greater social disadvantage.
Review pp. 165-166 on
Neural Bases of Social
Cognition and Function
Neural Bases of Social Cognition
Facial Recognition – fusiform gyrus and superior temporal sulcus
Emotion Perception – amygdala, insula, and ventral striatum
Higher-order social skills – frontal cortex (upcoming slide)
Theory of Mind (ToM) – medial prefrontal cortex, superior temporal
sulcus, temporo-parietal junction, and temporal poles
Empathy – mirror neuron system*, anterior cingulate cortex, regions
of somatosensory cortex and anterior insula
Moral reasoning – prefrontal regions, temporo-parietal junction
Mirror Neurons
Acharya, S. & Shukla, S. (2012).Mirror neurons:
Enigma of the metaphysical modular brain. J Nat Sci
Biol Med. 2012 Jul-Dec; 3(2): 118–124.
Found: premotor cortex, supplementary motor area,
primary somatosensory cortex, and inferior parietal
cortex
Mirror Neurons
Mirror Neurons
Cognitive Domains for Social Skills
3 higher-order cognitive domains are necessary
for social function
◦Attention and executive skills
◦interventions improve self-regulation,
problem solving & social competence
Cognitive Domains cont’d
◦Communication
◦ Comprehension
◦ Pragmatics
◦ Social skills progress quickly as expressive language emerges.
◦Social Cognition
◦ modulate appropriate behavior in social context
◦ ToM attributing mental states (beliefs, intents, desires, pretending,
knowledge) to oneself and others and understand another’s mental
state may differ
◦ “mental empathy”