Medico-Legal Issues of Intraoperative Neuromonitoring in Thyroid Surgery

Abstract

Advances in intraoperative neuromonitoring (IONM) in thyroid surgery have provided significant insights into recurrent laryngeal nerve function during thyroid surgery. Despite the limitations and necessary caution when using intraoperative monitors to interpret neural function, these technologies have been definite steps in the right direction for assessing neural integrity and safe surgical strategy during thyroid operations. The techniques discussed minimize the adverse sequelae of a variety of thyroid gland procedures, reducing the morbidity rates/risks in the perioperative period. Furthermore, it is likely that such monitoring will become a standard of care. Accurate, reliable and continuous monitoring is essential, and on-going large studies with definable end points will be necessary. The use of monitoring, such as continuous one, may improve cost efficiency by reducing permanent nerve injuries. A danger in this process, however, is the potential for public opinion, outside regulatory bodies, or medico-legal implications to drive change and enforce standards of care before appropriate data are available. Keywords Conflict of InterestNo potential conflict of interest relevant to this article was reported.procedure codes were evaluated for claimant information, insured's specialty, loss description, causation, and claim outcomes (1). During the 24-year period reviewed, 380 claims related to thyroid surgery were reported. One hundred twenty-eight claims (33.7% of total claims) resulted in an indemnity payment either due to settlement or a finding against the defendant. The average indemnity payment was $185,366 (range, $363 to $2,000,000). Among the cases in which a specific outcome was reported, 55 were related to laryngeal nerve injury or voice disturbance. No substantial change occurred in the incidence of claims across the study period. During this time, approximately $2,585,000 thyroidectomies were performed. Extrapolating from the PIAA data, this represents an estimated 5.9 claims per 10,000 cases (1).Using the LexisNexis Academic legal database, a retrospective review of all relevant federal and state cases from 1989 to 2009 was performed using the search terms "thyroid," "surgery," and "medical malpractice" (2). A total of 143 medical malpractice cases involving thyroid surgery were retrieved from our search from 1989 to 2009. After reviewing all cases, 33 cases in which the alleged negligence occurred after thyroid surgery were used for analysis. Of these cases, 15 involved recurrent laryngeal nerve (RLN) injury. Interestingly, no mention of RLN monitoring was noted in any of the cases (2).For the evaluation of a vocal cord paralysis (VCP) that has occurred after a thyroid surgery using intraoperative neuromonitoring (IONM), it is of crucial importance to take into account whether or not the published standards for proper use of IONM were applied correctly, and whether or not changes of neuromonitoring signal and electromyogram (EMG) were correctly interpreted intraoperatively and accordingl...

Utilization Trends of Intraoperative Neuromonitoring for Anterior Cervical Discectomy and Fusion in New York State

“…29,30,32 Likewise, electing to not use IONM, especially in urban centers in NY state, may place surgeons in legal peril as the rate of utilization rapidly increases. 31,32 Our study also highlights the uneven distribution of IONM technology. Laratta et al 2 showed a nearly 3-fold increase in the utilization of IONM between 2008 and 2014.…”

“…For spinal deformity surgery, it is well established that IONM represents the standard of care in the United States and other developed nations,29 however, the same is not clear for ACDF. Standards of care, in the legal sense, are established according to accepted locoregional norms 30,31. Although it is deceivingly simple to consider IONM as protective against litigation, it can be a “double-edged sword” when it is not accurately interpreted or inappropriately neglected 29,30,32.…”

“…Standards of care, in the legal sense, are established according to accepted locoregional norms. 30,31 Although it is deceivingly simple to consider IONM as protective against litigation, it can be a "double-edged sword" when it is not accurately interpreted or inappropriately neglected. 29,30,32 Likewise, electing to not use IONM, especially in urban centers in NY state, may place surgeons in legal peril as the rate of utilization rapidly increases.…”

The Consistency of Intraoperative Neural Monitoring in Thyroid Surgery

“…One of the concerns relating to guidelines in the field of IONM is related to their medicolegal implications (13)(14)(15)(16)(17)(18)(19). Some reports suggest that the courts are applying new clinical practice guidelines in their decision-making processes, it is worthwhile to anecdotally recall a case in which a patient sustained RLN palsy after thyroid surgery, and the plaintiffs' expert supported the view that IONM was considered the standard of care (13)(14)(15)(16)(17)(18)(19).…”