Recurrent laryngeal nerve injury with incomplete loss of electromyography signal during monitored thyroidectomy-evaluation and outcome.

Abstract

During monitored thyroidectomy, a partially or completely disrupted point of nerve conduction on the exposed recurrent laryngeal nerve (RLN) indicates true electrophysiologic nerve injury. Complete loss of signal (LOS; absolute threshold value <100μV) at the end of operation often indicates a postoperative vocal cord (VC) palsy. However, the evaluation for the injured RLN with incomplete LOS and its functional outcome has not been well described. Three hundred twenty-three patients with 522 RLNs at risk who underwent standardized monitored thyroidectomy were enrolled. The RLN was routinely stimulated at the most proximal (R2p signal) and distal (R2d signal) ends of exposure after thyroid resection to determine if there was an injured point on the RLN. Pre- and postoperative VC function was routinely examined. Twenty-nine RLNs (5.6%) were detected with an injury point. Five nerves had complete LOS and other 24 nerves had incomplete LOS where the R2p/R2d reduction (% of amplitude reduction compared with proximal to distal RLN stimulation) ranged from 22 to 79%. Postoperative temporary VC palsy was noted in those five RLNs with complete LOS (final vagal signal, V2 < 100μV) and four RLNs with incomplete LOS (R2p/R2d reduction 62-79%; V2 181-490μV). In the remaining 20 nerves with R2p/R2d reduction ≤53% (V2 373-1623μV), all showed normal VC mobility. Overall, false negative results were found in two RLNs (0.4%) featuring unchanged V2 and R2p/R2d but developed VC palsy. Testing and comparing the R2p/R2d signal is a simple and useful procedure to evaluate RLN injury after its dissection and predict functional outcome. When the relative threshold value R2p/R2d reduction reaches over 60%, surgeon should consider the possibility of postoperative VC palsy.