Neck dissection revisited

Abstract

Neck dissection, first described by Crile [1] in 1906, has become the most frequently performed surgical procedure in head and neck oncology. Now that 100 years have passed since its introduction, it is timely and worthwhile to reassess the past, present and future of the procedure. In Crile’s time, neck dissection was one of the most challenging surgical procedures. When I read his article [1], I was very much astounded that the last one-third of the paper was dedicated to the argument about how to prevent ‘‘shock’’ during surgery. During the following 40 years, neck dissection became safer and more common with the advancement of anesthesia and surgical techniques. In 1951, Martin established the concept of radical neck dissection [2]. In this procedure, the indication (clinical metastases in the cervical lymph nodes from head and neck cancer), extent of resection of cervical lymph nodes (submental, submandibular, deep cervical, spinal accessory and supraclavicular nodes) and extent of resection of nonlymphatic structures (internal jugular vein, spinal accessory nerve and sternocleidomastoid muscle) were clearly defined. Because radical neck dissection was greatly effective against neck metastases of head and neck cancer, it soon became the first choice of treatment, and its use became widespread worldwide. To date, radical neck dissection is one of the most effective treatments for cervical lymph node metastases. As radical neck dissection became popular, its disadvantages also started to surface, of which the biggest was impaired postoperative functions including shoulder disability and neck deformity [3, 4]. Although a wider application of neck dissection was recommended by some surgeons in the form of elective neck dissection [5] and synchronous bilateral neck dissection [6], it was almost impossible to extend the indication of radical neck dissection owing to many postoperative dysfunctions. Around 1960, a gradual and laborious task was initiated by a large number of surgeons to establish a new dissection method with better postoperative functions than and as excellent outcomes as radical neck dissection. This resulted in the invention of a wide variety of new methods, the most popular of which are ‘‘functional neck dissection’’ [7, 8] (where the internal jugular vein, spinal accessory nerve and sternocleidomastoid muscle are preserved) and ‘‘selective neck dissection’’ [9] (where the extent of resection of cervical lymph nodes does not include all the lymph nodes resected in radical neck dissection). Because the establishment of a new dissection method was an extremely difficult process, each surgeon addressed the problem in a distinctive type of patient through a distinctive approach. Therefore, new nonradical neck dissections diversified into procedures, each with individual background, indication and contraindication. Although the effectiveness of these new procedures was initially doubted, it was gradually established [10]. At present, nonradical neck dissections are the standard treatment most frequently performed in head and neck surgery. Although nonradical neck dissections certainly improved postoperative functions, their diversification created another problematic situation, that is, a total confusion about the terminology, indications and detailed maneuvers of neck dissections. This situation eventually led to an extreme diversity of neck dissections performed recently in Japan, prompting the organization of the Japan Neck Dissection Study Group (JNDSG). Details regarding M. Saikawa (&) Division of Head and Neck Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577, Japan e-mail: mhsaikaw@east.ncc.go.jp