title: Prognostic value of intraoperative neural monitoring of the recurrent laryngeal nerve in thyroid surgery.
abstract: OBJECTIVE
  The diagnostic accuracy of intraoperative recurrent laryngeal nerve (RLN) monitoring (IONM) remains controversial. The aim of this study was to evaluate IONM diagnostic accuracy in prognostication of postoperative nerve function in thyroid surgery.
  
  
  METHODS
  This prospective study was conducted in 2011-2013. Five hundred consenting patients qualified for total thyroidectomy with IONM (1000 nerves at risk) using NIM 3.0 Response equipment were included. Laryngoscopy was used to evaluate and follow up RLN injury. The primary outcome was diagnostic accuracy of IONM. The receiver operating characteristics (ROC) were used for evaluation of IONM diagnostic accuracy.
  
  
  RESULTS
  Loss of signal (LOS) occurred in 31 cases, including 25 patients with LOS and corresponding vocal fold paresis found in postoperative laryngoscopy (2.5 %), including 20 (2.0 %) temporary and 5 (0.5 %) permanent nerve lesions. The following diagnostic accuracy values were calculated for the criterion recommended by INMSG (V2 amplitude ≤ 100 μV): sensitivity 92.0 %, specificity 99.3 %, positive predictive value (PPV) 76.7 %, and negative predictive value (NPV) 99.8 %. The ROC curve analysis allowed for calculation of the most optimal criterion in prognostication of postoperative vocal fold paresis, namely, V2 amplitude ≤ 189 μV. For this criterion, PPV was 77.4 %, while NPV was 99.9 %.
  
  
  CONCLUSIONS
  Adherence to the standardized protocol recommended by the International Neural Monitoring Study Group allows for optimizing predictive values of IONM in prognostication of postoperative RLN function. Any changes in the cutoff values for the definition of LOS only marginally improve PPV and NPV of IONM and need to be carefully assessed in multicenter studies.
authors.affiliation: Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Kraków, Poland.
authors.forename: Małgorzata
authors.initials: M
authors.lastname: Stopa
authors.affiliation: Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Kraków, Poland. marbar@mp.pl.|Third Chair and Department of General Surgery, Jagiellonian University, Medical College, 37 Prądnicka Street, 31-202, Kraków, Poland. marbar@mp.pl.
authors.forename: Marcin
authors.initials: M
authors.lastname: Barczyński
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004576:Electromyography / Q000379:methods; D005260:Female; D006111:Graves Disease / Q000175:diagnosis / Q000601:surgery; D006801:Humans; D007828:Laryngoscopy / Q000379:methods; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000379:methods; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D061226:Recurrent Laryngeal Nerve Injuries / Q000517:prevention & control*; D018570:Risk Assessment; D013964:Thyroid Neoplasms / Q000473:pathology / Q000601:surgery; D013965:Thyroidectomy / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome; D014826:Vocal Cord Paralysis / Q000517:prevention & control*
keywords: Intraoperative neuromonitoring; Prognostic value; Recurrent laryngeal nerve; Staged thyroidectomy; Thyroid surgery