Liddy Whitney, Wu Che-Wei, Dionigi Gianlorenzo, Donatini Gianluca, Giles Senyurek Yasemin, Kamani Dipti, Iwata Ayaka, Wang Bo, Okose Okenwa, Cheung Anthony, Saito Yoshiyuki, Casella Claudio, Aygun Nurcihan, Uludag Mehmet, Brauckhoff Katrin, Carnaille Bruno, Tunca Fatih, Barczyński Marcin, Kim Hoon Yub, Favero Emerson, Innaro Nadia, Vamvakidis Kyriakos, Serpell Jonathan, Romanchishen Anatoly F, Takami Hiroshi, Chiang Feng-Yu, Schneider Rick, Dralle Henning, Shin Jennifer J, Abdelhamid Ahmed Amr H, Randolph Gregory W
Department of Otolaryngology-Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Kaohsiung Medical University Hospital, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
Thyroid. 2021 Nov;31(11):1730-1740. doi: 10.1089/thy.2021.0155.
The recurrent laryngeal nerve (RLN) can be injured during thyroid surgery, which can negatively affect a patient's quality of life. The impact of intraoperative anatomic variations of the RLN on nerve injury remains unclear. Objectives of this study were to (1) better understand the detailed surgical anatomic variability of the RLN with a worldwide perspective; (2) establish potential correlates between intraoperative RLN anatomy and electrophysiologic responses; and (3) use the information to minimize complications and assure accurate and safe intraoperative neuromonitoring (IONM). A large international registry database study with prospectively collected data was conducted through the International Neural Monitoring Study Group (INMSG) evaluating 1000 RLNs at risk during thyroid surgery using a specially designed online data repository. Monitored thyroid surgeries following standardized IONM guidelines were included. Cases with bulky lymphadenopathy, IONM failure, and failed RLN visualization were excluded. Systematic evaluation of the surgical anatomy of the RLN was performed using the International RLN Anatomic Classification System. In cases of loss of signal (LOS), the mechanism of neural injury was identified, and functional evaluation of the vocal cord was performed. A total of 1000 nerves at risk (NARs) were evaluated from 574 patients undergoing thyroid surgery at 17 centers from 12 countries and 5 continents. A higher than expected percentage of nerves followed an abnormal intraoperative trajectory (23%). LOS was identified in 3.5% of NARs, with 34% of LOS nerves following an abnormal intraoperative trajectory. LOS was more likely in cases of abnormal nerve trajectory, fixed splayed or entrapped nerves (including at the ligament of Berry), extensive neural dissection, cases of cancer invasion, or when lateral lymph node dissection was needed. Traction injury was found to be the most common form of RLN injury and to be less recoverable than previous reports. Multicenter international studies enrolling diverse patient populations can help reshape our understanding of surgical anatomy during thyroid surgery. There can be significant variability in the anatomic and intraoperative characteristics of the RLN, which can impact the risk of neural injury.
喉返神经（RLN）在甲状腺手术过程中可能会受到损伤，这会对患者的生活质量产生负面影响。RLN术中解剖变异对神经损伤的影响尚不清楚。本研究的目的是：（1）从全球视角更好地了解RLN详细的手术解剖变异性；（2）建立术中RLN解剖结构与电生理反应之间的潜在关联；（3）利用这些信息将并发症降至最低，并确保术中神经监测（IONM）准确、安全。通过国际神经监测研究组（INMSG）开展了一项大型国际注册数据库研究，使用专门设计的在线数据存储库对甲状腺手术期间1000条有风险的RLN进行前瞻性数据收集。纳入遵循标准化IONM指南的受监测甲状腺手术病例。排除有巨大淋巴结病、IONM失败和RLN可视化失败的病例。使用国际RLN解剖分类系统对RLN的手术解剖结构进行系统评估。在信号丢失（LOS）的病例中，确定神经损伤的机制，并对声带进行功能评估。对来自12个国家和5个大洲17个中心的574例接受甲状腺手术患者的1000条有风险神经（NAR）进行了评估。术中神经走行异常的神经比例高于预期（23%）。在3.5%的NAR中发现了LOS，其中34%的LOS神经术中走行异常。在神经走行异常、固定展开或受压神经（包括在Berry韧带处）、广泛的神经解剖、癌症侵犯病例或需要进行侧方淋巴结清扫时，更有可能出现LOS。发现牵拉伤是RLN损伤最常见的形式，且比以前的报告中更难恢复。纳入不同患者群体的多中心国际研究有助于重塑我们对甲状腺手术中手术解剖结构的理解。RLN的解剖和术中特征可能存在显著变异性，这会影响神经损伤风险。
