Surgical Department 1, Insulinoma GEP Tumor Center Neuss-Düsseldorf, Lukaskrankenhaus Neuss, Preussenstr. 84, 41456, Neuss, Germany.
World J Surg. 2010 Jun;34(6):1274-84. doi: 10.1007/s00268-009-0353-3.
Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve and the vagal nerve can detect nonfunctioning nerves (recurrent laryngeal nerve palsy, RLNP) that are visibly intact. The use of IONM is questionable, however, as we still lack evidence that it reduces the rate of postoperative nerve injuries. Since negative IONM results after thyroid dissection of the first side could change our surgical strategy and thus could prevent patients from bilateral RLNP, we questioned whether IONM results are reliable enough to base changes in surgical strategy and whether this has any effect on surgical outcome.
We retrospectively analyzed the data of 1333 consecutive patients with suggested benign bilateral thyroid disease who had been operated on under a defined protocol, including the use of a specific IONM technique (tube electrodes and stimulation of the vagal nerve and the inferior recurrent nerve before and after thyroid resection), between January 1, 2006 and December 31, 2008.
In four patients the IONM system did not work, two nerves had not been found, and in eight patients the tube had to be readjusted. Of five permanent nerve injuries, four were visible during surgery and one was suspected. Sensitivity of IONM in detecting temporary nerve injuries of macroscopically normal-appearing nerves was 93%. Specificity was 75-83% at first side of dissection and 55-67% at the second side, with an overall specificity of 77%. In 11 of 13 patients (85%) with known nerve injury (preexisting or visible) and in 20 of 36 patients (56%) with negative IONM stimulation at the first side of dissection, the surgical strategy was changed (specific surgeon or restricted resection) with no postoperative bilateral RLNP. This was in contrast to 3 of 18 (17%) bilateral RLNP (p < 0.05), when surgeons were not aware of a preexisting or highly likely nerve injury at the first side of thyroid dissection.
Failed IONM stimulation of the vagal or recurrent laryngeal nerve after resection of the first thyroid lobe is specific enough to reconsider the surgical strategy in patients with bilateral thyroid disease to surely prevent bilateral RLNP.
术中神经监测（IONM）可检测到看似完整但实际上已丧失功能的喉返神经和迷走神经（喉返神经麻痹，RLNP）。然而，IONM 的应用存在争议，因为我们仍然缺乏证据表明它可以降低术后神经损伤的发生率。由于第一侧甲状腺解剖后负的 IONM 结果可能会改变我们的手术策略，从而防止双侧 RLNP，我们质疑 IONM 结果是否足够可靠，以改变手术策略，以及这是否对手术结果有任何影响。
我们回顾性分析了 2006 年 1 月 1 日至 2008 年 12 月 31 日期间，根据一项明确的方案，在 1333 例疑似双侧良性甲状腺疾病的连续患者中使用特定的 IONM 技术（管电极和在甲状腺切除前后刺激迷走神经和下喉返神经）进行手术的资料。
有 4 例患者的 IONM 系统无法工作，2 例神经未找到，8 例患者的管需要重新调整。在 5 例永久性神经损伤中，4 例在手术中发现，1 例可疑。IONM 检测大体正常的神经暂时损伤的敏感性为 93%。初次解剖侧的特异性为 75-83%，第二次解剖侧的特异性为 55-67%，总体特异性为 77%。在 13 例已知神经损伤（既往或可见）患者中的 11 例（85%）和初次解剖侧 IONM 刺激阴性的 36 例患者中的 20 例（56%）中，手术策略发生了改变（特定外科医生或限制切除），没有术后双侧 RLNP。这与初次甲状腺解剖时外科医生未意识到存在或极有可能发生神经损伤的 18 例患者中的 3 例（双侧 RLNP，17%）形成对比（p<0.05）。
切除第一叶甲状腺后，迷走神经或喉返神经的 IONM 刺激失败特异性足够高，足以在双侧甲状腺疾病患者中重新考虑手术策略，以确保预防双侧 RLNP。
