Objective To observe the effect of anatomical and pathological variations of recurrent laryngeal nerve (RLN) on the 4-step intraoperative nerve monitoring (IONM), and to provide theoretical support and application strategy for standardized operation of IONM. Methods The clinical data of 160 patients who underwent thyroid cancer surgery with help of IONM in our hospital from June 2012 to December 2014 were retrospectively analyzed. The pa-tients were divided into variation group (n=55, anatomic variation, pathological variation) and non-variation group (n=105) according to the morphological characteristics of RLN. The effect of anatomical and pathological variations of RLN on the 4-step IONM was evaluated. Results A total of 297 nerves were detected intraoperatively, including 103 nerves with variation and 194 nerves without variation. In the variation group, a total of 92 nerves were success-fully recognized, with the recognition rate of 89.32%(92/103), and 11 nerves (11/103, 10.68%) were hard recog-nized. In the non-variation group, all the 194 nerves were recognized successfully, with the recognition rate of 100%. The difference in the recognition rate between the two groups was statistically significant (P<0.05). RLNs were detected in tracheoesophageal groove (194 cases, 65.32%), beside the trachea (75 cases, 25.25%), beside the esophagus (17 cases, 5.72%), and in the thyroid gland (11 cases, 3.71%). For prediction of postopera-tive vocal cord paralysis by EMG waveform from RLN stimulation, the negative predictive value was 100%and the positive predictive value was only 25.00%. Conclusion Variation of RLN brings trouble in mapping RLN by 4-step IONM and obtaining R1 signal, which interferes the identification of EMG waveform. Accurate recognition of RLN ana-tomical and pathological characteristics is conducive to enhancing standardized operation of IONM.%目的 观察甲状腺癌喉返神经(RLN)发生解剖病理变异时对术中神经监测(IONM) 4步法的影响,为IONM规范化操作提供理论支持及应用策略.方法 回顾性分析2012年6月至2014年12月在解放军总医院普通外科行甲状腺癌手术并于术中行IONM的160例的临床资料,根据术中显露RLN形态特征,分为变异组55例(解剖变异、病理变异)与无变异组105例.评估RLN解剖病理变异对IONM 4步法操作的影响.结果 术中显露RLN共297根.RLN识别率变异组为89.32%(92/103)顺利识别,其中11根(10.68%,11/103)寻找困难;无变异组100%均顺利识别,两组比较差异有统计学意义(P<0.05);术中RLN显露部位为气管食管沟内194根(65.32%)、气管旁75根(25.25%)、食管旁17根(5.72%)、甲状腺腺体内11根(3.71%);评价术后刺激RLN所得EMG波形对诊断术后声带麻痹的灵敏性与特异性,发现阴性预测值100%,阳性预测值仅25.00%.结论 RLN变异造成IONM4步法操作时RLN定位困难,R1值难以获取,干扰EMG波形研读;准确认知RLN解剖病理学形态特征,有利于提升IONM规范化操作水平.
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