Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy
Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy
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DOI：
10.1016/j.jamcollsurg.2007.07.017
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发表时间：
2008-01-01
影响因子：
5.2
通讯作者：
Roberts, John W.
中科院分区：
文献类型：
--
作者：
Snyder, Samuel K.;Lairmore, Terry C.;Roberts, John W.
背景：甲状腺切除术、甲状旁腺切除术或相关中央颈手术期间的术中神经监测可以阐明喉返神经 (RLN) 损伤的实际或潜在机制，尤其是视觉上完整的神经，这是内分泌外科医生以前未知的。 研究设计-在这项前瞻性评估研究中，373 名患者使用术中神经监测连续接受了 380 例甲状腺切除术或甲状旁腺切除术相关手术，其中 666 处 RLN 存在风险。记录了 RLN 视觉和功能识别的成功、RLN 功能对神经刺激的持续丧失、RLN 损伤的机制和位置、RLN 的解剖结构或可能对 RLN 损伤造成潜在风险的技术困难。 结果：在 98.2% 的危险神经中，通过视觉或功能识别出 RLN。最初术中 RLN 损伤发生在 25 个危险神经中（3.75%）。与横切的 RLN (n = 3; 0.45%) 相比，视觉上完整的 RLN (n = 22; 3.3%) 更有可能，p < 0.001。 2 个 RLN (0.3%) 持续瘫痪。视觉错误识别仅导致 1 例 RLN 损伤；最常见的损伤原因是 Berry 韧带附近分叉 RLN 前运动分支的牵引 (n = 7; 28%)，然后是气管旁淋巴结清扫术 (n = 6; 24%)、结扎术 (n = 4; 16%) 和粘连癌 (n = 4; 16%)。 50 条处于危险中的神经 (7.5%) 被确定为特别容易受伤的神经，最显着的是那些具有解剖变异的神经 (n = 26; 52%) 和大或血管甲状腺叶 (n = 19; 38%)。 结论：在甲状腺切除术或甲状旁腺切除术期间，术中 RLN 损伤发生在视觉上完整的 RLN 中，其发生率明显高于横断神经。 RLN 的前运动分支在 Berry 韧带附近分叉，特别容易受到牵引损伤。
BACKGROUND: Intraoperative nerve monitoring during thyroidectomy, parathyroidectomy, or related central neck procedures can elucidate actual or potential mechanisms of recurrent laryngeal nerve (RLN) injury, especially visually intact nerves, which were previously unknown to the endocrine surgeon.STUDY DESIGN- In this prospective evaluation study, 373 patients underwent 380 consecutive thyroidectomy- or parathyroidectomy-related operations using intraoperative nerve monitoring, with 666 RLNs at risk. The success of visual and functional identification of the RLN, persistent loss of RLN function to nerve stimulation, the mechanism and location of RLN injury, and anatomy of the RLN or technical difficulties that appeared potentially risky for RLN injury were recorded.RESULTS: RLN was identified visually or functionally in 98.2% of nerves at risk. Initial intraoperative injury to the RLN occurred in 25 nerves at risk (3.75%). It was significantly more likely to be a visually intact RLN (n = 22; 3.3%) than a transected RLN (n = 3; 0.45%), p < 0.001. Paralysis persisted in 2 RLNs (0.3%). Visual misidentification accounted for only 1 RLN injury; the most common cause of injury resulted from traction to the anterior motor branch of a bifurcated RLN near the ligament of Berry (n = 7; 28%), then paratracheal lymph node dissection (n = 6; 24%), incorporating ligature (n = 4; 16%), and adherent cancer (n = 4; 16%). Fifty nerves at risk (7.5%) were identified as particularly at risk for injury, most notably those with anatomic variants (n = 26; 52%) and large or vascular thyroid lobes (n = 19; 38%).CONCLUSIONS: RLN injury during thyroldectomy or parathyroidectomy occurs intraoperatively significantly more often to a visually intact RLN than to a transected nerve. The anterior motor branch of an RLN bifurcating near the ligament of Berry is particularly at risk of traction injury.