Validity of intra-operative neuromonitoring signals in thyroid surgery

Thomusch, Oliver; Sekulla, Carsten; Machens, Andreas; Neumann, H J; Timmermann, W.; Dralle, Henning

doi:10.1007/s00423-003-0444-9

Cited by 174 publications

(179 citation statements)

References 18 publications

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“…Similarly in our study, while there was no significant difference between the two groups in terms of RLN paralysis, the duration of operation in the group with nerve monitoring was significantly shorter. Even though some studies report that nerve dissection using IONM reduces the rate of permanent nerve damage following surgery [11][12][13][14], there is no consensus on this subject [15][16][17]. As the results of our study support us, we clinically suppose that nerve monitoring does not provide any contribution to an experienced surgeon; however, it might be used to assist less experienced surgeons with anatomical identification.…”

Section: Discussionsupporting

confidence: 64%

“…During surgery, methods such as the palpation of cricothyroid muscle synchronous with the nerve impulse, observation of the movement of vocal cords by using direct or fiberoptic nasopharyngoscopy, measurement of the pressure on the endotracheal tube exerted by the movement of vocal cords, placement of electrodes on the vocal cord muscles, and formation of contact between the vocal cord mucosa and the electrodes placed on the surface of the endotracheal tube are performed [7][8][9][10]. Whereas in some studies, it has been reported that nerve dissection using intraoperative nerve monitoring (IONM) reduces the rate of permanent nerve damage following surgery [11][12][13][14], there is no consensus on this subject [15][16][17]. This study aims to compare and contrast the effects of two different technical approaches-visual identification of RLN combined with IONM and no RLN identification-on RLN damage in total thyroidectomy.…”

Section: Introductionmentioning

confidence: 99%

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Is Nerve Monitoring Required in Total Thyroidectomy? Cerrahpasa Experience

et al. 2013

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Thyroidectomy is an elective operation performed in an anatomically complex region in which certain structures are responsible for vital functions and special senses. This study aims to compare the effects of two different technical approaches-nerve dissection combined with intraoperative nerve monitoring (IONM) and no nerve identification-on recurrent laryngeal nerve (RLN) damage in total thyroidectomy. One hundred and sixty-one consecutive cases that underwent total thyroidectomy and 322 RLN under risk were evaluated. In group 1 (n=162), nerve dissection combined with IONM was performed, whereas no RLN identification was performed in group 2 (n=160). While the duration of operation in group 1 (34.23±12.21 min) was statistically shorter than that in group 2 (36.98±16.79 min, p=0.017), there was no significant difference between groups related to RLN palsy (group 1 n=10, group 2 n=7). Use of IONM was found only to shorten the duration of operation. According to our presented experience, there is no benefit of IONMcombined routine dissection of RLN during total thyroidectomy on the prevention of RLN palsy.

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Section: Discussionsupporting

confidence: 64%

Section: Introductionmentioning

confidence: 99%

Is Nerve Monitoring Required in Total Thyroidectomy? Cerrahpasa Experience

et al. 2013

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“…Most studies conclude that IONM can be reliably used to predict normal cord function where nerve signal is intact and therefore has a high negative predictive value, on the order of 92-100%. 4,14,61 This is particularly the case when the identified nerve responds to less than 0.5 mA of stimulation. 62 Conversely, little information is gained when the IONM signal is lost/absent.…”

Section: The Role Of Ionmmentioning

confidence: 99%

“…Intraoperative loss of signal may indicate nerve injury or incorrect electrode placement/ equipment failure; it is therefore strongly suggested that IONM not be used as the sole method of RLN identification and preservation. 4,14,55,57,61,63 There is a lack of high-level evidence (i.e. level A, randomized control trials) to elucidate the true RLN sparing effect of IONM.…”

Section: The Role Of Ionmmentioning

confidence: 99%

Recurrent laryngeal nerve injury in thyroid surgery: a review

Hayward

Grodski

Yeung

et al. 2012

ANZ Journal of Surgery

207

129

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Recurrent laryngeal nerve palsy (RLNP) is an important and potentially catastrophic complication of thyroid surgery. Permanent RLNP occurs in 0.3-3% of cases, with transient palsies in 5-8%. A literature review and analysis of recent data regarding RLNP in thyroid surgery was performed, with particular focus on the identification of high-risk patients, the role of intraoperative identification and dissection of the nerve, and the role of intraoperative neuromonitoring (IONM) and optimal perioperative nerve assessment. In conjunction with the review, data from the Monash University/ Alfred Hospital Endocrine Surgery Unit between January 2007 and October 2011 were retrospectively analysed, including 3736 consecutive nerves at risk (NAR). The current literature and our data confirm that patients undergoing re-operative thyroid surgery and thyroid surgery for malignancies are at increased risk of RLNP. Intraoperative visualization and capsular dissection of the RLN remain the gold standard for intraoperative care during thyroid surgery for reducing RLNP risk. IONM should not be used as the sole mechanism for identifying and preserving the nerve, although it can be used to aid in the identification and dissection of the nerve, and may aid in nerve protection in high-risk cases including cancer surgery and re-operative surgery.

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“…Irrespective of the operative strategy of a 1-way or 2-way approach, the ipsilateral RLN (R2) and vagal stimulation (V2) after the completion of all operative measures serve for the detection of the RLN function and the prediction of a postoperatively intact or injured vocal fold function (3,(13)(14)(15)(16)(17)(18)(19)(20)(21). In post-resection intact VN signal and EMG, intact VC mobility can be assumed in more than 99% of the cases ( Table 3).…”

Section: Post-resectional Vagal Nerve Stimulation (V2) Recurrent Stimentioning

confidence: 99%

Medico-Legal Issues of Intraoperative Neuromonitoring in Thyroid Surgery

et al. 2017

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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...

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Validity of intra-operative neuromonitoring signals in thyroid surgery

Cited by 174 publications

References 18 publications

Is Nerve Monitoring Required in Total Thyroidectomy? Cerrahpasa Experience

Is Nerve Monitoring Required in Total Thyroidectomy? Cerrahpasa Experience

Recurrent laryngeal nerve injury in thyroid surgery: a review

Medico-Legal Issues of Intraoperative Neuromonitoring in Thyroid Surgery

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