Exploration of Optimal Current Intensity for Neural Monitoring of Vagus Nerve and Recurrent Laryngeal Nerve During The Thyroid and Parathyroid Surgery_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

 DENGQiao-lian ^1,2 , WEITao ¹ , LIUFeng ¹ , ZOUXiu-he ¹ ,  ZHUJing-qiang ¹

1. Diagnosis and Treatment Center of Thyroid and Parathyroid Disease, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China;
2. Department of Thyroid and Breast Surgery, The Fisrt People's Hospital of Zigong City, Zigong 643000, Sichuan Province, China;

Corresponding author：

ZHUJing-qiang, Email: zjq-wkys@163.com

Keywords：

Stimulation current intensity; Intraoperative neuromonitoring; Thyroid surgery; Parathyroid surgery

DOI：

10.7507/1007-9424.20160082

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Objective To explore optimal current intensity for neural monitoring of vagus nerve and recurrent laryngeal nerve during the thyroid and parathyroid surgery, so that we can judge function, location, identify, and protect the nerve more effectively and more quickly. Method A total of 100 patients who underwent thyroid or parathyroid operations by the same surgeon in West China Hospital, meanwhile accepted intraoperative neuromonitoring (IONM), and 186 nerves at risk were enrolled in this study. According to the standardized process of nerve monitoring, we stimulated the vagus nerve with the current strength of 1-5 mA, and respectively stimulated laryngeal recurrent nerve with 1-3 mA indirectly and directly, and recorded the amplitude of electromyographic signal, and changes of heart rate and blood pressure during the process. The purpose was seeking the optimum current strength for each stage of IONM. Results In 186 vagus nerves being tested, when monitoring the vagus nerve outside the carotid sheath, 109 vagus nerves (58.6%) sent out signals and got stable electromyography and warning tone with 1 mA, 164 (88.2%) vagus nerves had signals with 2 mA, 177 (95.2%) vagus nerves had signals with 3 mA, 182 (97.8%) vagus nerves had signals with 5 mA. Before and after the vagus nerve stimulation, heart rate and blood pressure of patients had no significant change. When directly monitoring the vagus nerve with 1 mA, V1 signals had no response in 2 vagus nerves (1.1%), V2 signals had no response in 9 vagus nerves (4.8%). But if the current intensity of stimulation was 2 mA or 3 mA, all patients got stable electromyographic signals. When searching for the laryngeal recurrent nerve, 92 (49.5%) got signals with 1 mA, 171 (91.9%) got signals with 2 mA, 184 (98.9%) got signals with 3 mA. When identifying laryngeal recurrent nerve and others, if the intensity of current was more than 2 mA, the current might conduct around and produce illusion. However, if the intensity of stimulation current was 1 mA, there's no electromyographic signal when we put the probe onto the tissue close to the laryngeal recurrent nerve. During identification of branches of laryngeal recurrent nerve with current strength of 1 mA, each electromyographic signal could be obtained. The chief branch into the throat produced the highest amplitude. The esophagus and trachea branch emg amplitude value was similar, equalling to 1/3-1/4 of the amplitude value in chief branch. Conclusions We suggest using current intensity of 5 mA on the surface of the carotid sheath to monitor the vagus nerve indirectly and obtain V1 signal, as an alternative to opening the carotid sheath. If fail, dissecting the carotid sheath, and using current intensity of 3 mA to monitor the vagus nerve directly; 3 mA is the optimal current intensity to search for the laryngeal recurrent nerve, and 1 mA is the optimal current intensity to identify the laryngeal recurrent nerve and its branches of esophagus and trachea, blood vessels, and so on.

Citation： DENGQiao-lian, WEITao, LIUFeng, ZOUXiu-he, ZHUJing-qiang. Exploration of Optimal Current Intensity for Neural Monitoring of Vagus Nerve and Recurrent Laryngeal Nerve During The Thyroid and Parathyroid Surgery. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2016, 23(3): 304-309. doi: 10.7507/1007-9424.20160082 Copy

1.	中国医师协会外科医师分会甲状腺外科医师委员会. 甲状腺及甲状腺旁腺术中神经电生理监测临床指南(中国版). 中国实用外科杂志, 2013, 33(6): 470-474.
2.	Tsai CJ, Tseng KY, Wang FY, et al. Electromyographic endotracheal tube placement during thyroid surgery in neuromonitoring of recurrent laryngeal nerve. Kaohsiung J Med Sci, 2011, 27(3): 96-101.
3.	Dionigi G, Chiang FY, Rausei S, et al. Surgical anatomy and neuro- physiology of the vagus nerve (VN) for standardised intraoperative neuromonitoring (IONM) of the inferior laryngeal nerve (ILN) during thyroidectomy. Langenbecks Arch Surg, 2010, 395(7): 893-899.
4.	Randolph GW, Dralle H; International Intraoperative Monitoring Study Group, et al. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope, 2011, 121 Suppl 1: S1-S16.
5.	Chiang FY, Lee KW, Chen HC, et al. Standardization of intraopera-tive neuromonitoring of recurrent laryngeal nerve in thyroid opera-tion. World J Surg, 2010, 34(2): 223-229.
6.	Chiang FY, Lu IC, Kuo WR, et al. The mechanism of recurrent laryngeal nerve injury during thyroid surgery-the application of intraoperative neuromonitoring. Surgery, 2008, 143(6): 743-749.
7.	Chiang FY, Lu IC, Tsai CJ, et al. Does extensive dissection of recurrent laryngeal nerve during thyroid operation increase the risk of nerve injury? Evidence from the application of intraoperative neuromonitoring. Am J Otolaryngol, 2011, 32(6): 499-503.
8.	Lu IC, Tsai CJ, Wu CW, et al. A comparative study between 1 and 2 effective doses of rocuronium for intraoperative neuromonitoring during thyroid surgery. Surgery, 2011, 149(4): 543-548.
9.	Brauckhoff M, Walls G, Brauckhoff K, et al. Identification of the non-recurrent inferior laryngeal nerve using intraoperative neurostimulation. Langenbecks Arch Surg, 2002, 386(7): 482-487.
10.	孙辉, 刘晓莉, 赵涛, 等. 术中神经监测识别非返性喉返神经6例经验. 中华内分泌外科杂志, 2010, 4(6): 402-404.
11.	Brauckhoff M, Machens A, Sekulla C, et al. Latencies shorter than 3.5 ms after vagus nerve stimulation signify a nonrecurrent inferior laryngeal nerve before dissection. Ann Surg, 2011, 253(6): 1172-1177.
12.	Chiang FY, Lu IC, Tsai CJ, et al. Detecting and identifying nonrecu-rrent laryngeal nerve with the application of intraoperative neuro-monitoring during thyroid and parathyroid operation. Am J Otolar-yngol, 2012, 33(1): 1-5.
13.	Donatini G, Carnaille B, Dionigi G. Increased detection of non-recurrent inferior laryngeal nerve (NRLN) during thyroid surgery using systematic intraoperative neuromonitoring (IONM). World J Surg, 2013, 37(1): 91-93.
14.	Chiang FY, Lu IC, Chen HC, et al. Anatomical variations of recu-rrent laryngeal nerve during thyroid surgery: how to identify and handle the variations with intraoperative neuromonitoring. Kaohsiung J Med Sci, 2010, 26(11): 575-583.
15.	Dralle H, Sekulla C, Haerting J, et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery, 2004, 136(6): 1310-1322.
16.	Friedrich C, Ulmer C, Rieber F, et al. Safety analysis of vagal nerve stimulation for continuous nerve monitoring during thyroid surgery.Laryngoscope, 2012, 122(9): 1979-1987.
17.	Wu CW, Lu IC, Randolph GW, et al. Investigation of optimal intensity and safety of electrical nerve stimulation during intraopera-tive neuromonitoring of the recurrent laryngeal nerve: a prospective porcine model. Head Neck, 2010, 32(10): 1295-1301.
18.	Wu CW, Dionigi G, Chen HC, et al. Vagal nerve stimulation without dissecting the carotid sheath during intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid surgery. Head Neck, 2013, 35(10): 1443-1447.
19.	Hayward NJ, Grodski S, Yeung M, et al. Recurrent laryngeal nerve injury in thyroid surgery: a review. ANZ J Surg, 2013, 83(1-2): 15-21.
20.	Alesina PF, Rolfs T, Hommeltenberg S, et al. Intraoperative neuro-monitoring does not reduce the incidence of recurrent laryngeal nerve palsy in thyroid reoperations: results of a retrospective comp-arative analysis. World J Surg, 2012, 36(6): 1348-1353.
21.	Cavicchi O, Caliceti U, Fernandez IJ, et al. Laryngeal neuromoni-toring and neurostimulation versus neurostimulation alone in thyroid surgery: a randomized clinical trial. Head Neck, 2012, 34(2): 141-145.
22.	孙辉, 刘晓莉, 付言涛, 等. 术中神经监测技术在复杂甲状腺手术中的应用. 中国实用外科杂志, 2010, 30(1): 66-68.
23.	魏涛, 李志辉, 朱精强. 喉返神经探测仪实时监测在再次甲状腺手术中的应用. 中国普外基础与临床杂志, 2010, 17(8): 772-774.
24.	蒋家著, 郑海涛, 孙翌祥, 等. 高风险甲状腺手术中喉返神经监测应用价值的探讨. 中华肿瘤防治杂志, 2012, 19(20): 1557-1559.
25.	Dionigi G, Barczynski M, Chiang FY, et al. Why monitor the recurrent laryngeal nerve in thyroid surgery?. J Endocrinol Invest, 2010, 33(11): 819-822.
26.	刘晓莉, 孙辉, 郑泽霖, 等. 甲状腺术中喉返神经监测技术的应用与进展. 中国普通外科杂志, 2009, 18(11): 1187-1190.
27.	刘春萍, 黄韬. 甲状腺手术喉返神经损伤的原因及处理探讨. 中国普外基础与临床杂志, 2008, 15(5): 314-317.
28.	付言涛, 周乐, 张大奇, 等. 非肉眼可见的喉返神经损伤的机制及其预防：术中神经监测系统在甲状腺手术中的应用. 中华内分泌外科杂志, 2011, 5(4): 268-270.
29.	赵诣深, 刘晓莉, 王铁, 等. 甲状腺手术中喉返神经功能与术后声带运动的相关性研究. 中国普外基础与临床杂志, 2015, 22(7): 784-787.
30.	Wu CW, Dionigi G, Sun H, et al. Intraoperative neuromonitoring for the early detection and prevention of RLN traction injury in thyroid surgery: a porcine model. Surgery, 2014, 155(2): 329-339.
31.	Lee HY, Cho YG, You JY, et al. Traction injury of the recurrentlaryngeal nerve: results of continuous intraoperative neuromoni-toring in a swine model. Head Neck, 2014. [Epub ahead of print].

1. 中国医师协会外科医师分会甲状腺外科医师委员会. 甲状腺及甲状腺旁腺术中神经电生理监测临床指南(中国版). 中国实用外科杂志, 2013, 33(6): 470-474.
2. Tsai CJ, Tseng KY, Wang FY, et al. Electromyographic endotracheal tube placement during thyroid surgery in neuromonitoring of recurrent laryngeal nerve. Kaohsiung J Med Sci, 2011, 27(3): 96-101.
3. Dionigi G, Chiang FY, Rausei S, et al. Surgical anatomy and neuro- physiology of the vagus nerve (VN) for standardised intraoperative neuromonitoring (IONM) of the inferior laryngeal nerve (ILN) during thyroidectomy. Langenbecks Arch Surg, 2010, 395(7): 893-899.
4. Randolph GW, Dralle H; International Intraoperative Monitoring Study Group, et al. Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: international standards guideline statement. Laryngoscope, 2011, 121 Suppl 1: S1-S16.
5. Chiang FY, Lee KW, Chen HC, et al. Standardization of intraopera-tive neuromonitoring of recurrent laryngeal nerve in thyroid opera-tion. World J Surg, 2010, 34(2): 223-229.
6. Chiang FY, Lu IC, Kuo WR, et al. The mechanism of recurrent laryngeal nerve injury during thyroid surgery-the application of intraoperative neuromonitoring. Surgery, 2008, 143(6): 743-749.
7. Chiang FY, Lu IC, Tsai CJ, et al. Does extensive dissection of recurrent laryngeal nerve during thyroid operation increase the risk of nerve injury? Evidence from the application of intraoperative neuromonitoring. Am J Otolaryngol, 2011, 32(6): 499-503.
8. Lu IC, Tsai CJ, Wu CW, et al. A comparative study between 1 and 2 effective doses of rocuronium for intraoperative neuromonitoring during thyroid surgery. Surgery, 2011, 149(4): 543-548.
9. Brauckhoff M, Walls G, Brauckhoff K, et al. Identification of the non-recurrent inferior laryngeal nerve using intraoperative neurostimulation. Langenbecks Arch Surg, 2002, 386(7): 482-487.
10. 孙辉, 刘晓莉, 赵涛, 等. 术中神经监测识别非返性喉返神经6例经验. 中华内分泌外科杂志, 2010, 4(6): 402-404.
11. Brauckhoff M, Machens A, Sekulla C, et al. Latencies shorter than 3.5 ms after vagus nerve stimulation signify a nonrecurrent inferior laryngeal nerve before dissection. Ann Surg, 2011, 253(6): 1172-1177.
12. Chiang FY, Lu IC, Tsai CJ, et al. Detecting and identifying nonrecu-rrent laryngeal nerve with the application of intraoperative neuro-monitoring during thyroid and parathyroid operation. Am J Otolar-yngol, 2012, 33(1): 1-5.
13. Donatini G, Carnaille B, Dionigi G. Increased detection of non-recurrent inferior laryngeal nerve (NRLN) during thyroid surgery using systematic intraoperative neuromonitoring (IONM). World J Surg, 2013, 37(1): 91-93.
14. Chiang FY, Lu IC, Chen HC, et al. Anatomical variations of recu-rrent laryngeal nerve during thyroid surgery: how to identify and handle the variations with intraoperative neuromonitoring. Kaohsiung J Med Sci, 2010, 26(11): 575-583.
15. Dralle H, Sekulla C, Haerting J, et al. Risk factors of paralysis and functional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery, 2004, 136(6): 1310-1322.
16. Friedrich C, Ulmer C, Rieber F, et al. Safety analysis of vagal nerve stimulation for continuous nerve monitoring during thyroid surgery.Laryngoscope, 2012, 122(9): 1979-1987.
17. Wu CW, Lu IC, Randolph GW, et al. Investigation of optimal intensity and safety of electrical nerve stimulation during intraopera-tive neuromonitoring of the recurrent laryngeal nerve: a prospective porcine model. Head Neck, 2010, 32(10): 1295-1301.
18. Wu CW, Dionigi G, Chen HC, et al. Vagal nerve stimulation without dissecting the carotid sheath during intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid surgery. Head Neck, 2013, 35(10): 1443-1447.
19. Hayward NJ, Grodski S, Yeung M, et al. Recurrent laryngeal nerve injury in thyroid surgery: a review. ANZ J Surg, 2013, 83(1-2): 15-21.
20. Alesina PF, Rolfs T, Hommeltenberg S, et al. Intraoperative neuro-monitoring does not reduce the incidence of recurrent laryngeal nerve palsy in thyroid reoperations: results of a retrospective comp-arative analysis. World J Surg, 2012, 36(6): 1348-1353.
21. Cavicchi O, Caliceti U, Fernandez IJ, et al. Laryngeal neuromoni-toring and neurostimulation versus neurostimulation alone in thyroid surgery: a randomized clinical trial. Head Neck, 2012, 34(2): 141-145.
22. 孙辉, 刘晓莉, 付言涛, 等. 术中神经监测技术在复杂甲状腺手术中的应用. 中国实用外科杂志, 2010, 30(1): 66-68.
23. 魏涛, 李志辉, 朱精强. 喉返神经探测仪实时监测在再次甲状腺手术中的应用. 中国普外基础与临床杂志, 2010, 17(8): 772-774.
24. 蒋家著, 郑海涛, 孙翌祥, 等. 高风险甲状腺手术中喉返神经监测应用价值的探讨. 中华肿瘤防治杂志, 2012, 19(20): 1557-1559.
25. Dionigi G, Barczynski M, Chiang FY, et al. Why monitor the recurrent laryngeal nerve in thyroid surgery?. J Endocrinol Invest, 2010, 33(11): 819-822.
26. 刘晓莉, 孙辉, 郑泽霖, 等. 甲状腺术中喉返神经监测技术的应用与进展. 中国普通外科杂志, 2009, 18(11): 1187-1190.
27. 刘春萍, 黄韬. 甲状腺手术喉返神经损伤的原因及处理探讨. 中国普外基础与临床杂志, 2008, 15(5): 314-317.
28. 付言涛, 周乐, 张大奇, 等. 非肉眼可见的喉返神经损伤的机制及其预防：术中神经监测系统在甲状腺手术中的应用. 中华内分泌外科杂志, 2011, 5(4): 268-270.
29. 赵诣深, 刘晓莉, 王铁, 等. 甲状腺手术中喉返神经功能与术后声带运动的相关性研究. 中国普外基础与临床杂志, 2015, 22(7): 784-787.
30. Wu CW, Dionigi G, Sun H, et al. Intraoperative neuromonitoring for the early detection and prevention of RLN traction injury in thyroid surgery: a porcine model. Surgery, 2014, 155(2): 329-339.
31. Lee HY, Cho YG, You JY, et al. Traction injury of the recurrentlaryngeal nerve: results of continuous intraoperative neuromoni-toring in a swine model. Head Neck, 2014. [Epub ahead of print].

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Exploration of Optimal Current Intensity for Neural Monitoring of Vagus Nerve and Recurrent Laryngeal Nerve During The Thyroid and Parathyroid Surgery

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