术中神经监测信号异常在判断甲状腺癌手术喉返神经损伤类型与转归中的作用研究

Role of abnormal IONM signal in judging the type and prognosis of recurrent laryngeal nerve injury in thyroid cancer surgery

目的探讨术中神经监测(IONM)信号异常在判断甲状腺癌手术喉返神经(RLN)损伤的类型与转归中的作用。方法回顾性分析2018年1月至2020年12月在首都医科大学附属北京友谊医院普外科确诊行甲状腺癌根治术并应用IONM的705例甲状腺癌病人临床资料。根据IONM结果、手术记录、术后症状,以及喉镜检查结果,分析IONM信号异常原因、RLN损伤及类型,研究IONM信号异常在判断RLN损伤的类型与转归中的作用。结果705例病人中,63例(8.9%)IONM信号异常,包括RLN真性损伤42例(5.9%),短暂性损伤11例(1.6%),假损伤10例(1.4%)。与RLN短暂性损伤和假损伤相比,肿瘤侵犯或粘连(21.4%,9/42)是RLN真性损伤的重要原因(P<0.05),后者均出现术后喉镜结果异常,64.3%出现术后声音嘶哑或饮水呛咳症状。此外,RLN显性损伤9例(1.3%),RLN非显性损伤44例(6.2%)。RLN显性损伤均为真性损伤;非显性损伤者中,33例为真性损伤(4.6%)、11例为短暂性损伤(1.6%)。此外,IONM一过性信号异常占RLN真性损伤者21.4%,短暂性损伤者90.9%,假损伤者40.0%,差异有统计学意义(P<0.05);IONM信号异常部位,信号衰减幅度与RLN损伤类型差异无统计学意义(P>0.05)。结论甲状腺癌术中IONM信号异常可能源于RLN真性损伤、短暂性损伤或假损伤。即使RLN外观正常,术者应重视一过性IONM信号异常,如不及时终止操作,对RLN加以保护,短暂性损伤可能成为真性损伤。在未使用IONM情况下,RLN短暂性损伤可能被忽视,真性损伤可能增加。

Objective To explore the role of abnormal intraoperative neuromonitoring(IONM)signal in judging the type and prognosis of recurrent laryngeal nerve(RLN)injury in thyroid cancer(TC)surgery.Methods The clinical data of 705 patients who underwent TC radical surgery by using IONM in Department of general surgery of Beijing Friendship Hospital affiliated to Capital Medical University from January 2018 to December 2020 were analyzed retrospectively.Based on the IONM results,surgical records,postoperative symptoms and laryngoscopy results,the causes of abnormal IONM signal were analyzed;RLN injury and types were determined;the role of abnormal IONM signal in judging the type and prognosis of RLN injury in TC surgery were identified.Results Among the 705 cases,63 patients had abnormal IONM signal(8.9%).Among them,there were 42 cases of RLN true injury(5.9%),11 cases of temporary injury(1.6%)and 10 cases of false injury(1.4%).Compared with temporary injury and false injury of RLN,tumor invasion or adhesion(21.4%,9/42)is an important cause of true injury of RLN(P<0.05).The results of laryngoscope are abnormal after operation,and 64.3%have postoperative hoarseness and/or cough caused by drinking water.In addition,44 cases(6.2%)had non-overt RLN appearance and 9 cases(1.3%)had dominant RLN appearance.Among them,the dominant appearance of RLN is the true injury of RLN;for non-overt appearance,33 cases were RLN true injuries(4.6%)and 11 cases were temporary injuries(1.6%).The ratio of transient signal abnormality of IONM in different RLN injury types is significantly different(P<0.05):21.4%(9/42)of true RLN injury,90.9%(10/11)of temporary injury and 40%(4/10)of false injury.There was no significant difference between the transient abnormal IONM signal,signal attenuation amplitude and type of RLN injury.Conclusion IONM signal abnormality in TC surgeries can be attributed to RLN true injury,temporary injury and false injury.Even if the appearance of RLN is normal during operation,the operator should pay attention to transient IONM signal abnormality,which may be true injury.Without IONM,the temporary injury of RLN may be ignored and the real injury may increase.