Dionigi Gianlorenzo, Wu Che-Wei, Kim Hoon Yub, Rausei Stefano, Boni Luigi, Chiang Feng-Yu
1st Division of General Surgery, Department of Surgical Sciences and Human Morphology, Research Center for Endocrine Surgery, University of Insubria (Varese-Como), via Guicciardini 9, 21100, Varese, Italy.
Department of Otolaryngology-Head and Neck Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100TzYou 1st Road, Kaohsiung City, 807, Taiwan.
World J Surg. 2016 Jun;40(6):1373-81. doi: 10.1007/s00268-016-3415-3.
Few studies in the literature have reported recovery data for different types of recurrent laryngeal nerve injuries (RLNIs). This study is the first attempt to classify RLNIs and rank them by severity.
This prospective clinical study analyzed 281 RLNIs in which a true loss of signal was identified by intraoperative neuromonitoring (IONM), and vocal cord palsy (VCP) was confirmed by a postoperative laryngoscope. For each injury type, the prevalence of VCP, the time of VCP recovery, and physical changes on nerves were analyzed. Additionally, different RLNI types were experimentally induced in a porcine model to compare morphological change.
The overall VCP rate in at-risk patients/nerves was 8.9/4.6 %, respectively. The distribution of RLNI types, in order of frequency, was traction (71 %), thermal (17 %), compression (4.2 %), clamping (3.4 %), ligature entrapment (1.6 %), suction (1.4 %), and nerve transection (1.4 %). Complete recovery from VCP was documented in 91 % of RLNIs. Recovery time was significantly faster in the traction group compared to the other groups (p < 0.001). The rates of temporary and permanent VCP were 98.6 and 1.4 % for traction lesion, 72 and 28 % for thermal injury, 100 and 0 % for compression injury, 50 and 50 % for clamping injury, 100 and 0 % for ligature entrapment, 100 and 0 % for suction injury, and 0 and 100 % for nerve transection, respectively. Physical changes were noted in 14 % of RLNIs in which 56 % of VCP was permanent. However, among the remaining 86 % IONM-detectable RLNIs without physical changes, only 1.2 % of VCP was permanent. A porcine model of traction lesion showed only distorted outer nerve structure, whereas the thermal lesion showed severe damage in the inner endoneurium.
Different RNLIs induce different morphological alterations and have different recovery outcomes. Permanent VCP is rare in lesions that are visually undetectable but detectable by IONM. By enabling early detection of RLNI and prediction of outcome, IONM can help clinicians plan intra- and postoperative treatment.
文献中很少有研究报告不同类型喉返神经损伤（RLNIs）的恢复数据。本研究首次尝试对RLNIs进行分类并按严重程度排序。
这项前瞻性临床研究分析了281例RLNIs，术中神经监测（IONM）确定存在真正的信号丧失，术后喉镜检查证实存在声带麻痹（VCP）。分析了每种损伤类型的VCP患病率、VCP恢复时间以及神经的物理变化。此外，在猪模型中实验性诱导不同类型的RLNI以比较形态学变化。
高危患者/神经的总体VCP发生率分别为8.9%/4.6%。RLNI类型的分布频率依次为牵拉（71%）、热损伤（17%）、压迫（4.2%）、钳夹（3.4%）、结扎卡压（1.6%）、吸引（1.4%）和神经横断（1.4%）。91%的RLNIs记录到VCP完全恢复。与其他组相比，牵拉组的恢复时间明显更快（p<0.001）。牵拉损伤的临时和永久性VCP发生率分别为98.6%和1.4%，热损伤为72%和28%，压迫损伤为100%和0%，钳夹损伤为50%和50%，结扎卡压为100%和0%，吸引损伤为100%和0%，神经横断为0%和100%。14%的RLNIs出现了物理变化，其中56%的VCP是永久性的。然而，在其余86%无物理变化且可通过IONM检测到的RLNIs中，只有1.2%的VCP是永久性的。牵拉损伤的猪模型仅显示神经外部结构扭曲，而热损伤显示神经内膜内部严重受损。
不同的RLNIs会引起不同的形态学改变，且恢复结果不同。在视觉上无法检测但可通过IONM检测到的损伤中，永久性VCP很少见。通过能够早期检测RLNI并预测结果，IONM可以帮助临床医生规划术中及术后治疗。
