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INTRAOPERATIVE NEUROMONITORING DURING THYROIDECTOMY- WHERE IS THE TRUTH?

Intraoperative
Neuromonitoring (IONM) has been proposed in recent years as a way to reduce the
likelihood of damage to the Recurrent Laryngeal Nerves (RLNs) (which control
the mobility of vocal cords, that is to say, the control / production of voice
[vocation]) during thyroid or parathyroid surgery. IONM is almost constantly
presented in the printed and electronic press, as well as in commercial
business listings, as a particularly effective and technologically impressive
aid in thyroid/parathyroid surgery, which ensures that the integrity of RLNs is
maintained.



Is
that the case?


However, beyond the field of medical industry, at an academic level, there is a significant gap in the studies evaluating the value of IONM. This important gap refers to the particularly problematic (in terms of scientific methodology) quality of these studies, which explains the widely contradictory results of these studies when comparing IONM versus visual identification and protection of RLNs. And when we refer to studies in this regard, we are not referring to presentations of the experience of a center or a surgeon with fewer or more patients, but to systematic reviews and meta-analyses. These systematic reviews- metaanalyses offer the most serious and reliable scientific data on which the clinical practice is based and potentially changed. Very recently, a particularly important article (JAMA Otolaryngology-Head and Neck Surgery, 2019) was published which included all IONM systemic reviews / metaanalyses from January 1968 to June 30, 2018 (a total of 13 in number).
These systematic reviews- metaanalyses offer the most reliable scie


ntific data, on which the clinical practice is based. In this article, the methodology of each systematic analysis / meta-analysis, the statistical processing of the data, the formulation of the conclusions, the heterogeneity of the studies, the publication bias, the FUNDING BY COMPANIES OR OTHER INSTITUTIONS (!!! , a particularly important parameter, for obvious reasons), potential conflicts of interest etc. were examined in detail. The quality of the scientific methodology of all these systematic reviews-metaanalyses was measured by two independent researchers using the AMSTAR2 tool (A Measurement Tool to Assess Systemic Reviews). The conclusion of this particularly interesting study (JAMA Otolaryngol Head Neck Surg 2019) was that the results of these 13 systematic reviews-metaanalyses are contradictory and that these 13 studies suffer from very significant gaps in methodology and scientific design. At the end of this very interesting study it is emphasized that systematic reviews – metaanalyses should be based on established methodological standards and be carefully designed to respond to important clinical questions and provide useful information that could be applied to the clinical practice (and possibly change the practice of surgery).
The conclusion is that enthusiastic support of IONM for all thyroid-parathyroid surgery does not seem to be based on highly reliable scientific data. The role of advertising a product of the medical industry as well as the physician using it should not be overlooked.