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To stim, or not to stim, that is the question

      Few nerves have consistently captured the attention of physicians, scientists, and the public more than the recurrent laryngeal nerve (RLN). From Galen's public demonstration that a pig will stop squealing after RLN ligation, to Richard Dawkins' dissection of the RLN in a giraffe in a modern nature documentary, the RLN's circuitous course has long been a source of spectacle.
      • Kaplan E.L.
      • Salti G.I.
      • Roncella M.
      • Fulton N.
      • Kadowaki M.
      History of the recurrent laryngeal nerve: from Galen to Lahey.
      ,
      • Burnett M.
      Inside Nature's Giants.
      To the thyroid surgeon, however, the RLN has historically been a source of angst, with a reported 25% rate of unilateral injury rate from Billroth's group in the 1800s.
      • Kaplan E.L.
      • Salti G.I.
      • Roncella M.
      • Fulton N.
      • Kadowaki M.
      History of the recurrent laryngeal nerve: from Galen to Lahey.
      Since then, iterative improvements in thyroidectomy technique have decreased nerve injury rates significantly. In contrast to Crile's philosophy of leaving the posterior capsule of the thyroid undisturbed, Lahey advocated for routine dissection and visualization of the RLN: now a standard practice for modern thyroidectomy.
      • Kaplan E.L.
      • Salti G.I.
      • Roncella M.
      • Fulton N.
      • Kadowaki M.
      History of the recurrent laryngeal nerve: from Galen to Lahey.
      The next advance in intraoperative management of the RLN came with the advent of intraoperative neural monitoring (IONM). Guidelines published from the International Neural Monitoring Study Group (INMSG) outline several advantages to IONM, including increased speed of RLN identification, identification of anatomical variants such as early branching or non-recurrent nerves, and prognostication of nerve function to guide intraoperative decision-making.
      • Schneider R.
      • Randolph G.W.
      • Dionigi G.
      • et al.
      International neural monitoring study group guideline 2018 part I: staging bilateral thyroid surgery with monitoring loss of signal.
      ,
      • Wu C.W.
      • Dionigi G.
      • Barczynski M.
      • et al.
      International neuromonitoring study group guidelines 2018: Part II: optimal recurrent laryngeal nerve management for invasive thyroid cancer-incorporation of surgical, laryngeal, and neural electrophysiologic data.
      While existing literature provides support for some of these applications of IONM, strong evidence demonstrating that IONM prevents RLN injury is conspicuously absent.

      Abbreviations:

      RLN (Recurrent laryngeal nerve), IONM (Intraoperative neural monitoring)
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