title: Continuous monitoring of the recurrent laryngeal nerve in thyroid surgery: a critical appraisal.
abstract: OBJECTIVE
  Intraoperative neuromonitoring (IONM) contributes in several ways to recurrent laryngeal nerve (RLN) protection. Notwithstanding these advantages, surgeons must be aware that the current, intermittent, mode of IONM (I-IONM) has relevant limitations. To overcome these I-IONM limitations, a continuous IONM (C-IONM) technology has been proposed.
  
  
  METHODS
  A PubMed indexed literature review of the current limitations of I-IONM is presented and a commentary about C-IONM is provided presenting the preliminary results of research on this topic.
  
  
  RESULTS
  I-IONM, despite the advantages it produces, presents some important limitations; to overcome these drawbacks a C-IONM technology has been introduced.
  
  
  CONCLUSIONS
  RLN traction injury is still the most common cause of RLN injury and is difficult to avoid with the application of I-IONM in thyroid surgery. C-IONM is useful to prevent the imminent traction injury by detecting progressive decreases in electromyographic amplitude combined with progressive latency increases. C-IONM seems to be a technological improvement. Likely, C-IONM by vagal nerve stimulation should enhance the standardization process, RLN intraoperative information, documentation, protection, training, and research in modern thyroid surgery. Although C-IONM is a promising technology at the cutting edge of research in thyroid surgery, we need more studies to assess in an evidence-based way all its advantages.
authors.affiliation: Division of General Surgery, Department of Surgical Sciences, University of Insubria, Varese-Como, Italy.
authors.forename: Gianlorenzo
authors.initials: G
authors.lastname: Dionigi
authors.affiliation: Chirurgia Generale delle Apuane, Asl 1 Toscana, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Donatini
authors.affiliation: Division of General Surgery, Department of Surgical Sciences, University of Insubria, Varese-Como, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Boni
authors.affiliation: Division of General Surgery, Department of Surgical Sciences, University of Insubria, Varese-Como, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Rausei
authors.affiliation: Division of General Surgery, Department of Surgical Sciences, University of Insubria, Varese-Como, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Rovera
authors.affiliation: Department of Clinical Medicine, Endocrinology, University of Insubria, Varese-Como, Italy.
authors.forename: Maria Laura
authors.initials: ML
authors.lastname: Tanda
authors.affiliation: Department of Surgery, Korea University College of Medicine, Seoul, Korea.
authors.forename: Hoon Yub
authors.initials: HY
authors.lastname: Kim
authors.affiliation: Department of Otolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan.
authors.forename: Feng-Yu
authors.initials: FY
authors.lastname: Chiang
authors.affiliation: Department of Otolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan.
authors.forename: Che-Wei
authors.initials: CW
authors.lastname: Wu
authors.affiliation: Division of General Surgery, Department of Surgical Sciences, University of Insubria, Varese-Como, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Mangano
authors.affiliation: Department of Surgery, University Hospital of Tor Vergata, Rome, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Rulli
authors.affiliation: Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Akademisches Lehrkrankenhaus der Universität Duisburg-Essen, Essen, Germany.
authors.forename: Piero F
authors.initials: PF
authors.lastname: Alesina
authors.affiliation: Division of General Surgery, Department of Surgical Sciences, University of Insubria, Varese-Como, Italy.
authors.forename: Renzo
authors.initials: R
authors.lastname: Dionigi
mesh_terms: D006801:Humans; D016343:Monitoring, Intraoperative / Q000379:methods; D012009:Recurrent Laryngeal Nerve / Q000502:physiology*; D061226:Recurrent Laryngeal Nerve Injuries / Q000517:prevention & control*; D013961:Thyroid Gland / Q000601:surgery*
keywords: C-IONM; Continuous intraoperative neuromonitoring; IONM; Thyroid surgery