Varied Recurrent Laryngeal Nerve Course Is Associated with Increased Risk of Nerve Dysfunction during Thyroidectomy: Results of the Surgical Anatomy of the Recurrent Laryngeal Nerve in Thyroid Surgery Study, an International Multicenter Prospective Anatomic and Electrophysiologic Study of 1000 Monitored Nerves at Risk from the International Neural Monitoring Study Group

Whitney Liddy*, Che Wei Wu, Gianlorenzo Dionigi, Gianluca Donatini, Yasemin Giles Senyurek, Dipti Kamani, Ayaka Iwata, Bo Wang, Okenwa Okose, Anthony Cheung, Yoshiyuki Saito, Claudio Casella, Nurcihan Aygun, Mehmet Uludag, Katrin Brauckhoff, Bruno Carnaille, Fatih Tunca, Marcin Barczyński, Hoon Yub Kim, Emerson FaveroNadia Innaro, Kyriakos Vamvakidis, Jonathan Serpell, Anatoly F. Romanchishen, Hiroshi Takami, Feng Yu Chiang, Rick Schneider, Henning Dralle, Jennifer J. Shin, Amr H. Abdelhamid Ahmed, Gregory W. Randolph

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

3 Scopus citations

Abstract

Background: 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). Methods: 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. Results: 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. Conclusions: 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.

Original languageEnglish (US)
Pages (from-to)1730-1740
Number of pages11
JournalThyroid
Volume31
Issue number11
DOIs
StatePublished - Nov 2021

Keywords

  • intraoperative neural monitoring
  • loss of signal
  • neural injury
  • recurrent laryngeal nerve
  • surgical anatomy
  • thyroid surgery

ASJC Scopus subject areas

  • Endocrinology, Diabetes and Metabolism
  • Endocrinology

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