Continuous intraoperative neural monitoring of the recurrent nerves in thyroid surgery: a quantum leap in technology

Schneider, Rick; Randolph, Gregory W.; Barczyński, Marcin; Dionigi, Gianlorenzo; Wu, Che‐Wei; Machens, Andreas; Kamani, Dipti; Dralle, Henning

doi:10.21037/gs.2016.11.10

Cited by 73 publications

(82 citation statements)

References 39 publications

(71 reference statements)

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“…Although CIONM augments vagal activity subclinically, this does not set off any counterregulation by the sympathetic nervous system (27). Experimental and clinical studies that investigated the issue more systematically did not uncover meaningful cardiac, pulmonary, or gastric vagal adverse effects (20,(28)(29)(30)(31)(32).…”

Section: Challenges Of Implementation and Technological Pitfalls Of Ionmmentioning

confidence: 99%

“…For meaningful interpretation of signals, baseline amplitudes need to be at least ≥500 µV after supra-threshold stimulation (1 mA) of the ipsilateral VN (19,20):…”

Section: Challenges Of Implementation and Technological Pitfalls Of Ionmmentioning

confidence: 99%

“…Low amplitude waveforms from bystander (non-target) muscles can be explained by the concept of far-field artefactual waveforms and do not reflect a true electrophysiological response from these muscles (22). For CIONM, the situation is completely different because artefacts pretending to show amplitude decreases in conjunction with latency increases can mimic so-called 'combined events' that herald impending nerve injury ( Figure 2B) (15,20).…”

Section: Challenges Of Implementation and Technological Pitfalls Of Ionmmentioning

confidence: 99%

“…Indeed, an observational study of 1,526 patients confirmed that operation with CIONM resulted in fewer permanent VF palsies compared with intermittent IONM (0 vs. 0.4%; P=0.019) after thyroid surgery in patients with benign disease (4). CIONM helps detect adverse EMG changes early on and prevent severe RLN injuries that cause LOS by permitting the surgeon to release distressed nerves (20,45,46). RLN injury comes in two varieties, which differ in many ways (47):…”

Section: Challenges Of Preventing Rln Palsy Under Ionmmentioning

confidence: 99%

“…Importantly, animal models cannot mimic human thyroid disease and differ greatly from humans in terms of laryngeal anatomy, formation of voice, as well as breathing and swallowing. In a sense, IONM is like a new language that needs to be learned (20). Particular attention should be placed on the occasional disconnect between RLN function and VF mobility, which is still incompletely understood.…”

Section: Future Perspectivesmentioning

confidence: 99%

See 4 more Smart Citations

Opportunities and challenges of intermittent and continuous intraoperative neural monitoring in thyroid surgery

Schneider¹,

Machens²,

Randolph³

et al. 2017

Gland Surg.

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Section: Challenges Of Implementation and Technological Pitfalls Of Ionmmentioning

confidence: 99%

“…For meaningful interpretation of signals, baseline amplitudes need to be at least ≥500 µV after supra-threshold stimulation (1 mA) of the ipsilateral VN (19,20):…”

Section: Challenges Of Implementation and Technological Pitfalls Of Ionmmentioning

confidence: 99%

Section: Challenges Of Implementation and Technological Pitfalls Of Ionmmentioning

confidence: 99%

Section: Challenges Of Preventing Rln Palsy Under Ionmmentioning

confidence: 99%

Section: Future Perspectivesmentioning

confidence: 99%

See 3 more Smart Citations

Opportunities and challenges of intermittent and continuous intraoperative neural monitoring in thyroid surgery

Schneider¹,

Machens²,

Randolph³

et al. 2017

Gland Surg.

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Experimental study of needle recording electrodes placed on the thyroid cartilage for neuromonitoring during thyroid surgery

Zhao

et al. 2019

Journal of British Surgery

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Background Needle electrodes placed on the thyroid cartilage (TC) are an alternative to endotracheal tube (ET) electrodes for assessing recurrent laryngeal nerve (RLN) function during thyroid surgery. Needle electrodes placed on the TC were evaluated in an experimental porcine model. Methods Continuous intraoperative neuromonitoring was used to record the electromyogram. Each TC side was delineated into nine areas to determine the optimal placement of the electrode, and needle electrode area, depth and orientation for optimal electromyographic (EMG) amplitudes were evaluated. RLN root locations were stimulated at four locations: vagus nerve distal to the neuromonitoring electrode, and most proximal, middle and laryngeal entry points of the nerve. A nerve retraction injury model was adapted to compare RLN monitoring by TC versus ET electrodes. Results An optimal site for placement of needle electrodes was identified, and electromyograms obtained from the various needle insertion depths and orientations were similar. Latencies recorded from the TC and ET electrodes were similar. The amplitude profile of TC electrodes responded earlier to RLN injury than that of ET electrodes. Amplitude and drop to loss of signal were also registered earlier. Conclusion EMG amplitudes obtained using TC electrodes were higher, and identified RLN injury earlier than ET electrodes. Needle electrodes placed on the thyroid cartilage (TC) are an alternative to endotracheal tube (ET) electrodes for assessing the function of the recurrent laryngeal nerve (RLN) in thyroid surgery.This study used an experimental porcine model to evaluate the use of needle electrodes inserted in the TC, compared with ET electrodes, for producing an electromyographic (EMG) profile of the RLN. Nine areas of the TC, with various needle insertion depths and orientations, were compared. Perichondral insertion into the avascular area of the TC was found to be safe. The EMG amplitude and latency features recorded via the TC and ET electrodes were compared, using both intermittent and continuous monitoring. Changes in EMG amplitudes in response to nerve traction injury were registered earlier with TC electrodes than with ET electrodes, and the amplitudes were higher and more stable. Latencies obtained via the TC and ET electrodes were similar.These results indicate that the development of a non‐invasive monitoring electrode with improved function, easy placement and low cost is possible.

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Meta‐analysis on continuous nerve monitoring in thyroidectomies

Hui

Cheung

et al. 2021

Head & Neck

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In the last decade, the introduction of continuous intraoperative recurrent laryngeal nerve (RLN) monitoring (C-IONM) has enabled the operator to verify the functional integrity of the vagus nerve-recurrent laryngeal nerve (VN-RLN) axis in real-time. We aim to present the current evidence on C-IONM utility for thyroid surgery by conducting the first meta-analysis on this technique. A systematic review of literature was conducted by two independent reviewers via Ovid in the Medline, EMBASE, and Cochrane reviews databases. The search was limited to human subject research in peer-reviewed articles of all languages published between Jan 1946 and April 2020. Medical subject headings (MeSH) terms utilized were thyroid surgery, thyroidectomies, recurrent laryngeal nerve, vagal nerve, monitor, and stimulation. Thirty-eight papers were identified from Ovid, another six papers were identified by hand-search. A random effect meta-analysis was performed with assessment of heterogeneity using the I 2 value. A total of 23 papers that investigated the use of continuous vagal nerve monitoring during thyroid surgery were identified. The proportion of nerves at risk (NAR) with temporary RLN paralysis postoperation was 2.26% (95% CI: 1.6-2.9, I 2 = 37). The proportion of NAR with permanent RLN palsy postoperation was 0.05% (95% CI: 0.08-0.2, I 2 = 0). In this meta-analysis, there is one case of temporary vagal nerve paralysis secondary to VN electrode dislodgement, and a case of hemodynamic instability manifested in bradycardia and hypotension in the initial phase of surgery shortly after calibration. C-IONM is a safe and effective means by which RLN paralyses in thyroid surgery can be reduced.

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Continuous intraoperative neural monitoring of the recurrent nerves in thyroid surgery: a quantum leap in technology

Cited by 73 publications

References 39 publications

Opportunities and challenges of intermittent and continuous intraoperative neural monitoring in thyroid surgery

Opportunities and challenges of intermittent and continuous intraoperative neural monitoring in thyroid surgery

Experimental study of needle recording electrodes placed on the thyroid cartilage for neuromonitoring during thyroid surgery

Meta‐analysis on continuous nerve monitoring in thyroidectomies

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