{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,29]],"date-time":"2026-05-29T19:09:20Z","timestamp":1780081760759,"version":"3.54.0"},"reference-count":30,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2022,8,11]],"date-time":"2022-08-11T00:00:00Z","timestamp":1660176000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100011645","name":"Kaohsiung Medical University Chung-Ho Memorial Hospital","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100011645","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100004663","name":"Ministry of Science and Technology, Taiwan","doi-asserted-by":"publisher","award":["MOST 110-2314-B-037-104-MY2"],"award-info":[{"award-number":["MOST 110-2314-B-037-104-MY2"]}],"id":[{"id":"10.13039\/501100004663","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Endocrinol."],"abstract":"<jats:sec><jats:title>Objectives<\/jats:title><jats:p>Traction injury is the most common type of recurrent laryngeal nerve (RLN) injury in thyroid surgery. Intraoperative neuromonitoring (IONM) facilitates early detection of adverse electromyography (EMG) effect, and this corrective maneuver can reduce severe and repeated nerve injury. This study aimed to evaluate intraoperative patterns and outcomes of EMG decrease and recovery by traction injury.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>644 patients received nerve monitored thyroidectomy with 1142 RLNs at risk were enrolled. Intermittent IONM with stimulating dissecting instrument (real-time during surgical procedure) and trans-thyroid cartilage EMG recording method (without electrode malpositioning issue) were used for nerve stimulation and signal recording. When an EMG amplitude showed a decrease of &amp;gt;50% during RLN dissection, the surgical maneuver was paused immediately. Nerve dissection was restarted when the EMG amplitude was stable.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>44\/1142 (3.9%) RLNs exhibited a &amp;gt;50% EMG amplitude decrease during RLN dissection and all (100%) showed gradual progressive amplitude recovery within a few minutes after releasing thyroid traction (10 recovered from LOS; 34 recovered from a 51-90% amplitude decrease). Three EMG recovery patterns were noted, A-complete EMG recovery (n=14, 32%); B-incomplete EMG recovery with an injury point (n=16, 36%); C-incomplete EMG recovery without an injury point (n=14, 32%). Patients with postoperative weak or fixed vocal cord mobility in A, B, and C were 0(0%), 7(44%), and 2(14%), respectively. Complete EMG recovery was found in 14 nerves, and incomplete recovery was found in another 30 nerves. Temporary vocal cord palsy was found in 6 nerves due to unavoidable repeated traction.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Early detection of traction-related RLN amplitude decrease allows monitoring of intraoperative EMG signal recovery during thyroid surgery. Different recovery patterns show different vocal cord function outcomes. To elucidate the recovery patterns can assist surgeons in the intraoperative decision making and postoperative management.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fendo.2022.888381","type":"journal-article","created":{"date-parts":[[2022,8,11]],"date-time":"2022-08-11T07:42:32Z","timestamp":1660203752000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":8,"title":["Intraoperative EMG recovery patterns and outcomes after RLN traction-related amplitude decrease during monitored thyroidectomy"],"prefix":"10.3389","volume":"13","author":[{"given":"Kuan-Lin","family":"Chiu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ching-Feng","family":"Lien","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chih-Chun","family":"Wang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chien-Chung","family":"Wang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tzer-Zen","family":"Hwang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yu-Chen","family":"Shih","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wing-Hei Viola","family":"Yu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Che-Wei","family":"Wu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gianlorenzo","family":"Dionigi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tzu-Yen","family":"Huang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Feng-Yu","family":"Chiang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2022,8,11]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","DOI":"10.1002\/hed.2890060606","article-title":"A safe technique for thyroidectomy with complete nerve dissection and parathyroid preservation","volume":"6","author":"Karlan","year":"1984","journal-title":"Head Neck Surg"},{"key":"B2","article-title":"Recurrent nerve palsy after thyroid operations\u2013principal nerve identification and a literature review","volume":"115","author":"Jatzko","year":"1994","journal-title":"Surgery"},{"key":"B3","doi-asserted-by":"publisher","DOI":"10.1097\/00005537-200201000-00022","article-title":"Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk","volume":"112","author":"Steurer","year":"2002","journal-title":"Laryngosc"},{"key":"B4","doi-asserted-by":"publisher","DOI":"10.1016\/j.surg.2004.09.008","article-title":"Recurrent laryngeal nerve palsy after thyroidectomy with routine identification of the recurrent laryngeal nerve","volume":"137","author":"Chiang","year":"2005","journal-title":"Surgery"},{"key":"B5","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamcollsurg.2007.07.017","article-title":"Elucidating mechanisms of recurrent laryngeal nerve injury during thyroidectomy and parathyroidectomy","volume":"206","author":"Snyder","year":"2008","journal-title":"J Am Coll Surg"},{"key":"B6","doi-asserted-by":"publisher","DOI":"10.1007\/s00268-016-3415-3","article-title":"Severity of recurrent laryngeal nerve injuries in thyroid surgery","volume":"40","author":"Dionigi","year":"2016","journal-title":"World J Surg"},{"key":"B7","doi-asserted-by":"publisher","DOI":"10.1016\/j.surg.2008.02.006","article-title":"The mechanism of recurrent laryngeal nerve injury during thyroid surgery\u2014the application of intraoperative neuromonitoring","volume":"143","author":"Chiang","year":"2008","journal-title":"Surgery"},{"key":"B8","doi-asserted-by":"publisher","DOI":"10.1007\/s00268-019-05178-6","article-title":"Traction injury of recurrent laryngeal nerve during thyroidectomy","volume":"44","author":"Liu","year":"2020","journal-title":"World J Surg"},{"key":"B9","doi-asserted-by":"publisher","DOI":"10.1007\/s00423-016-1381-8","article-title":"Recurrent laryngeal nerve injury with incomplete loss of electromyography signal during monitored thyroidectomy\u2014evaluation and outcome","volume":"402","author":"Wu","year":"2017","journal-title":"Langenb Arch Surg"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijsu.2020.08.058","article-title":"Mechanisms of recurrent laryngeal nerve injury near the nerve entry point during thyroid surgery: A retrospective cohort study","volume":"83","author":"Liu","year":"2020","journal-title":"Int J Surg"},{"key":"B11","doi-asserted-by":"publisher","DOI":"10.1016\/j.surg.2013.08.015","article-title":"Intraoperative neuromonitoring for the early detection and prevention of rln traction injury in thyroid surgery: A porcine model","volume":"155","author":"Wu","year":"2014","journal-title":"Surgery"},{"key":"B12","doi-asserted-by":"publisher","DOI":"10.1007\/s00423-016-1419-y","article-title":"EMG changes during continuous intraoperative neuromonitoring with sustained recurrent laryngeal nerve traction in a porcine model","volume":"402","author":"Brauckhoff","year":"2017","journal-title":"Langenb Arch Surg"},{"key":"B13","doi-asserted-by":"publisher","DOI":"10.1002\/hed.23187","article-title":"Continuous intraoperative vagus nerve stimulation for identification of imminent recurrent laryngeal nerve injury","volume":"35","author":"Schneider","year":"2013","journal-title":"Head Neck"},{"key":"B14","doi-asserted-by":"publisher","DOI":"10.1007\/s00268-012-1853-0","article-title":"Evolution of nerve injury with unexpected emg signal recovery in thyroid surgery using continuous intraoperative neuromonitoring","volume":"37","author":"Schneider","year":"2013","journal-title":"World J Surg"},{"key":"B15","doi-asserted-by":"publisher","DOI":"10.1002\/hed.26828","article-title":"Meta-analysis on continuous nerve monitoring in thyroidectomies","volume":"43","author":"Ku","year":"2021","journal-title":"Head Neck"},{"key":"B16","doi-asserted-by":"publisher","DOI":"10.1002\/lary.27144","article-title":"Continuous vagal monitoring value in prevention of vocal cord paralysis following thyroid surgery","volume":"128","author":"Kandil","year":"2018","journal-title":"Laryngosc"},{"key":"B17","doi-asserted-by":"publisher","first-page":"607","DOI":"10.21037\/gs.2016.11.10","article-title":"Continuous intraoperative neural monitoring of the recurrent nerves in thyroid surgery: A quantum leap in technology","volume":"5","author":"Schneider","year":"2016","journal-title":"Gland Surg"},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.1002\/lary.26392","article-title":"Changes in electromyographic amplitudes but not latencies occur with endotracheal tube malpositioning during intraoperative monitoring for thyroid surgery: Implications for guidelines","volume":"127","author":"Barber","year":"2017","journal-title":"Laryngosc"},{"key":"B19","doi-asserted-by":"publisher","DOI":"10.1007\/s00423-021-02217-6","article-title":"Drawbacks of neural monitoring troubleshooting algorithms in transoral endoscopic thyroidectomy","volume":"406","author":"Zhang","year":"2021","journal-title":"Langenb Arch Surg"},{"key":"B20","doi-asserted-by":"publisher","DOI":"10.1007\/s00268-009-0316-8","article-title":"Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation","volume":"34","author":"Chiang","year":"2010","journal-title":"World J Surg"},{"key":"B21","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamcollsurg.2005.09.025","article-title":"Detailed investigation of the relationship between the inferior laryngeal nerve including laryngeal branches and ligament of berry","volume":"202","author":"Yal\u00e7\u0131n","year":"2006","journal-title":"J Am Coll Surg"},{"key":"B22","doi-asserted-by":"publisher","DOI":"10.1016\/j.surg.2005.06.035","article-title":"Anatomic configurations of the recurrent laryngeal nerve and inferior thyroid artery","volume":"139","author":"Yalcxin","year":"2006","journal-title":"Surgery"},{"key":"B23","doi-asserted-by":"publisher","DOI":"10.1177\/000313481207800933","article-title":"Variations in the locations of the recurrent laryngeal nerve in relation to the ligament of berry","volume":"78","author":"John","year":"2012","journal-title":"Am Surg"},{"key":"B24","doi-asserted-by":"publisher","DOI":"10.1016\/S1607-551X(10)70089-9","article-title":"Anatomical variations of recurrent laryngeal nerve during thyroid surgery: How to identify and handle the variations with intraoperative neuromonitoring","volume":"26","author":"Chiang","year":"2010","journal-title":"Kaohsiung J Med Sci"},{"key":"B25","doi-asserted-by":"publisher","DOI":"10.1002\/lary.25251","article-title":"Stimulating dissecting instruments during neuromonitoring of rln in thyroid surgery","volume":"125","author":"Chiang","year":"2015","journal-title":"Laryngosc"},{"key":"B26","doi-asserted-by":"publisher","DOI":"10.1007\/s00268-017-4159-4","article-title":"Development of a novel detachable magnetic nerve stimulator for intraoperative neuromonitoring","volume":"42","author":"Sung","year":"2018","journal-title":"World J Surg"},{"key":"B27","doi-asserted-by":"publisher","DOI":"10.1002\/lary.28049","article-title":"Trans-thyroid cartilage recording for neural monitoring of the recurrent laryngeal nerve in thyroid surgery","volume":"130","author":"Chiang","year":"2020","journal-title":"Laryngosc"},{"key":"B28","doi-asserted-by":"publisher","DOI":"10.1002\/lary.27362","article-title":"Anterior laryngeal electrodes for recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: New expanded options for neural monitoring","volume":"128","author":"Liddy","year":"2018","journal-title":"Laryngosc"},{"key":"B29","doi-asserted-by":"publisher","DOI":"10.1016\/j.kjms.2017.06.014","article-title":"Comparison of EMG signals recorded by surface electrodes on endotracheal tube and thyroid cartilage during monitored thyroidectomy","volume":"33","author":"Chiang","year":"2017","journal-title":"Kaohsiung J Med Sci"},{"key":"B30","doi-asserted-by":"publisher","first-page":"19","DOI":"10.3978\/j.issn.2227-684X.2014.12.03","article-title":"Loss of signal in recurrent nerve neuromonitoring: Causes and management","volume":"4","author":"Wu","year":"2015","journal-title":"Gland Surg"}],"container-title":["Frontiers in Endocrinology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fendo.2022.888381\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,8,11]],"date-time":"2022-08-11T07:42:37Z","timestamp":1660203757000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fendo.2022.888381\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,8,11]]},"references-count":30,"alternative-id":["10.3389\/fendo.2022.888381"],"URL":"https:\/\/doi.org\/10.3389\/fendo.2022.888381","relation":{},"ISSN":["1664-2392"],"issn-type":[{"value":"1664-2392","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,8,11]]},"article-number":"888381"}}