Feasibility and safety of nerve stimulator attachment to energy-based devices: A porcine model study

Recent Developments of Intraoperative Neuromonitoring in Thyroidectomy

At present, intraoperative neuromonitorization (IONM) with surface electrode-based endotracheal tube (ETT) is a standard method in thyroidectomy and can be performed either intermittently IONM (I-IONM) or continuously IONM (C-IONM). Despite the valuable contribution of I-IONM to the thyroidectomy, it still has limitations regarding the recording electrodes and stimulation probe. New approaches for overcoming the limitations of I-IONM and developing the method are taking attention. Most of the technical issues of IONM with surface electrode-based ETT are related with inadequate contact of electrodes to the vocal cords. Nowadays, efficiency of various recording electrodes is under investigation. Recording electrodes such as needle electrodes applied to thyroarytenoid or posterior cricoarytenoid muscle (PCA), surface electrodes applied to the PCA, and needle or adhesive electrodes applied to the tracheal cartilage or skin, can make safe recordings similar to the ETT electrodes. Despite their invasiveness, needle electrodes record higher electromyography (EMG) amplitudes than tube electrodes do. Adhesive surface electrodes make safe EMG recordings, although amplitudes of these electrodes are usually lower than those of the tube electrodes. These different types of electrodes are less affected by tracheal manipulations and amplitude changes are lower compared to the tube electrodes.

During C-IONM, an additional stimulation probe is applied to the vagus nerve after dissecting the nerve circumferentially. Recently, without applying a probe, a new continuous monitorization method called laryngeal adductor reflex CIONM (LAR-CIONM) using sensorial, central, and motor components of LAR arch which is an automatic, primitive brainstem reflex protecting the tracheoesophageal tree from foreign body aspiration, has been implemented. Afferent track of LAR communicates laryngeal mucosa to the brainstem by internal branch of the superior laryngeal nerve and efferent track reaches larynx through recurrent laryngeal nerve. Total outcome of LAR activation is the closure of laryngeal entry by bilateral vocal cord adduction. In LAR-CIONM, a stimulus is given by an electrode from one side of surface electrode-based ETT and amplitude response of the LAR at the vocal cord is followed on the operation side. Recently, it has been reported that real-time EMG response can be obtained with stimulation probe cables applied to dissectors or energy devices during the dissection through I-IONM.

Investigation of attachment location of adhesive skin electrodes for intraoperative neuromonitoring in thyroid surgery: Preclinical and clinical studies

BACKGROUND

Recently, adhesive skin electrodes have been reported to be useful for recording electromyographic signals from intrinsic laryngeal muscles for intraoperative neuromonitoring in thyroid surgery and have shown good results compared to existing recording methods. In this study, we investigated the optimal attachment location of adhesive skin electrodes for intraoperative neuromonitoring in both porcine models and human cases.

METHODS

Attachment locations were divided vertically into upper, middle, and lower locations and horizontally into medial and lateral locations to determine the optimal location of placing adhesive skin electrodes preclinically in four porcine models. This study included a total of 78 patients who underwent thyroidectomy under intraoperative neuromonitoring with adhesive skin electrodes. Sixteen patients were monitored using both adhesive skin electrodes and an electromyographic endotracheal tube. Two pairs of skin electrodes were attached to the level of the thyroid cartilage lamina. Evoked electromyographic data, including data on mean amplitude and latency, obtained by stimulating the recurrent laryngeal nerve and vagus nerve, were collected.

RESULTS

Lateral attachment of adhesive skin electrodes showed significantly higher evoked amplitudes than medial attachment in both animal models and human patients. In cases where skin electrodes and an electromyographic endotracheal tube were used together, the electromyographic endotracheal tube showed a significantly higher amplitude than skin electrodes, and laterally attached skin electrodes showed a significantly higher amplitude than medially attached skin electrodes.

CONCLUSION

Intraoperative neuromonitoring using adhesive skin electrodes was feasible in both animal models and human patients. We suggest that it would be better to attach adhesive skin electrodes to the lateral side of the thyroid cartilage lamina. Lateral attachment closer to the cricoarytenoid joint may be better for measuring muscle movement around the cricoarytenoid joint.

Application of patch stimulator for intraoperative neuromonitoring during thyroid surgery: maximizing surgeon's convenience

Background

Intraoperative neuromonitoring (IONM) is frequently used in thyroid surgery to reduce recurrent laryngeal nerve (RLN) injury by providing the surgeon with real-time feedback on nerve stimulation during dissection. We applied a disposable adhesive patch electrode to a dissecting instrument to transfer electrical stimulation to the dissecting instrument for IONM during thyroid surgery. This study aimed to evaluate the feasibility of using the patch stimulator approach for IONM during thyroid surgery.

Methods

We reviewed the medical records of patients who underwent thyroidectomy using both conventional stimulator and adhesive patch stimulator for IONM. The electromyography (EMG) amplitudes of the vagal and the RLNs before (V1, R1) and after thyroid resection (V2, R2) were alternatively checked with each type of stimulator at the same location of each nerve.

Results

Fifteen consecutive patients (4 males, 11 females) were included in this analysis, and a total of 38 nerves (19 vagus nerves and 19 RLNs) were evaluated. No statistically significant differences were seen in the mean amplitudes evoked by the patch stimulator and the conventional probe stimulator for the V1 signal (825.5±394.6 vs. 821.8±360.9 µV, P=0.954), R1 signal (1,044.8±471.2 vs. 1,039.2±507.4 µV, P=0.898), R2 signal (1,037.8±495.0 vs. 938.2±415.8 µV, P=0.948), or V2 signal (812.5±391.9 vs. 787.3±355.7 µV, P=0.975).

Conclusions

The patch stimulator was safely and effectively used for IONM during thyroid surgery and provided similar nerve monitoring responses as the conventional stimulator. This approach may be used to enhance the surgeon's convenience during thyroid surgery.

Application of Novel Intraoperative Neuromonitoring System Using an Endotracheal Tube With Pressure Sensor During Thyroid Surgery: A Porcine Model Study

OBJECTIVES

The loss of signal during intraoperative neuromonitoring (IONM) using electromyography (EMG) in thyroidectomy is one of the biggest problems. We have developed a novel IONM system with an endotracheal tube (ETT) with an attached pressure sensor instead of EMG to detect laryngeal twitching. The aim of the present study was to investigate the feasibility and reliability of this novel IONM system using an ETT with pressure sensor during thyroidectomy in a porcine model.

METHODS

We developed an ETT-attached pressure sensor that uses the piezoelectric effect to measure laryngeal muscle twitching. Stimulus thresholds, amplitude, and latency of laryngeal twitching evaluated using the pressure sensor were compared to those measured using transcartilage needle EMG. The measured amplitude changes by EMG and the pressure sensor during recurrent laryngeal nerve (RLN) traction injury were compared.

RESULTS

No significant differences in stimulus threshold intensity between EMG and the pressure sensor were observed. The EMG amplitude detected at 0.3 mA, increased with increasing stimulus intensity. When the stimulus was more than 1.0 mA, the amplitude showed a plateau. In a RLN traction injury experiment, the EMG amplitude did not recover even 20 minutes after stopping RLN traction. However, the pressure sensor showed a mostly recovery.

CONCLUSION

The change in amplitude due to stimulation of the pressure sensor showed a pattern similar to EMG. Pressure sensors can be feasibly and reliably used for RLN traction injury prediction, RLN identification, and preservation through the detection of laryngeal muscle twitching. Our novel IONM system that uses an ETT with an attached pressure sensor to measure the change of surface pressure can be an alternative to EMG in the future.

Simple technique to preserve the external branch of the superior laryngeal nerve during thyroidectomy: Clinical practicability of an attachable nerve stimulator

OBJECTIVE

This study aimed to demonstrate the usefulness of an attachable magnetic nerve stimulator for preservation of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy.

METHODS

We retrospectively analyzed 120 female patients, of which 60 underwent thyroidectomy with an attachable magnetic nerve stimulator (magnetic group) and the remaining 60 underwent thyroidectomy with a conventional method without EBSLN identification (control group). For both groups, objective and subjective voice parameters were investigated on the day before surgery and at 2 weeks and 2 months after surgery.

RESULTS

In the magnetic group, a magnetic nerve stimulator was used to ligate only the site without cricothyroid muscle (CTM) twitching, and thyroid surgery was successfully performed without damage to the EBSLN. In the control group, objective voice parameters, including fundamental frequency, voice range profile (VRP), highest VRP (VRP-H), and maximal phonation time, and the subjective thyroidectomy-related voice questionnaire score were significantly decreased at 2 months after surgery compared to preoperative values. Compared to the control group, the magnetic group did not show a significant decrease in the objective VRP and VRP-H at 2 months after surgery.

CONCLUSION

The use of metallic surgical instruments with an attachable magnetic nerve stimulator may provide surgeons with real-time feedback on CTM twitching feedback and EBSLN status. Compared to direct EBSLN identification during thyroidectomy, this is a simple, easy, and noninvasive method for EBSLN preservation that is useful, especially for less-experienced surgeons.

Killian-Jamieson diverticulum safely resected using a manual intraoperative neural monitoring system: a case report

BACKGROUND

Killian-Jamieson diverticulum is a rare pharyngoesophageal diverticulum. The risk of intraoperative injury of the recurrent laryngeal nerve (RLN) is high during surgical resection of Killian-Jamieson diverticulum because the RLN usually runs next to the base of the diverticulum. We present a case of Killian-Jamieson diverticulum that was safely resected with effective use of an intraoperative nerve monitoring (IONM) system with a handheld stimulating probe to prevent RLN injury.

CASE PRESENTATION

A 69-year-old man complaining of dysphagia was diagnosed with Killian-Jamieson diverticulum and underwent open transcervical diverticulectomy. Because the anterior aspect of the diverticulum was expected to be close to the RLN, the accurate location of the RLN was checked during dissection by intermittent stimulation using a handheld probe of the IONM system to avoid mechanical and thermal injury. The diverticulum was transected longitudinally using a linear stapler, and the staple line was buried using absorbable sutures from the distal end. During its closure, RLN was identified very close to the diverticulum stump by IONM, and the upper side of the stump was left unburied to avoid RLN injury. The postoperative course was uneventful and the patient was discharged on postoperative day 7. Postoperative evaluation showed no vocal cord paralysis.

CONCLUSION

IONM may be beneficial during open surgery for Killian-Jamieson diverticulum, which usually protrudes just lateral to the RLN.

Feasibility of Attachable Ring Stimulator for Intraoperative Neuromonitoring during Thyroid Surgery

OBJECTIVE

Stimulator-attached dissecting instruments are useful for intraoperative nerve monitoring during thyroidectomy. The aim of this study was to evaluate the feasibility of an attachable ring stimulator (ARS) by comparing the electromyography (EMG) amplitudes evoked by an ARS and a conventional stimulator.

METHODS

Medical records of fourteen patients who underwent thyroidectomy using intraoperative neuromonitoring between June and August 2019 were retrospectively reviewed. The amplitudes of V1, R1, R2, and V2 signals were checked using both the ARS and a conventional stimulator, at the same point.

RESULTS

Both stimulators were tested on 20 recurrent laryngeal nerves (RLNs) and 20 vagus nerves (VNs). In all the nerves, the amplitudes of V1, R1, R2, and V2 were greater than 500 μV. The mean amplitudes of V1, R1, R2, and V2 checked with the ARS were 1175, 1432, 1598, and 1279 μV, respectively. The mean amplitudes of V1, R1, R2, and V2 checked with the conventional stimulator were 1140, 1425, 1557, and 1217 μV, respectively. Difference between amplitudes evoked by the two stimulators for V1, R1, R2, and V2 was 77, 110, 102, and 99 μV, respectively. There was no statistical difference in the amplitudes between the two groups for V1, R1, R2, and V2.

CONCLUSION

The ARS transferred electric stimulation as effectively as the conventional stimulator. It is an effective tool for repeated stimulation and facilitates continuous feedback regarding the functional integrity of nerves during thyroid surgery.

Development of a Novel Intraoperative Neuromonitoring System Using an Accelerometer Sensor in Thyroid Surgery: A Porcine Model Study

Objectives.

The sensitivity and positive predictive value of widely used intraoperative neuromonitoring (IONM) using electromyography (EMG) of the vocalis muscle in thyroid surgery are controversial. Thus, we developed a novel IONM system with an accelerometer sensor that uses the piezoelectric effect instead of EMG to detect laryngeal twitching. The objective of this study was to evaluate the feasibility and safety of this novel IONM system during thyroid surgery in a porcine model.

Methods.

We developed an accelerometer sensor that uses the piezoelectric effect to measure laryngeal twitching in three dimensions. This novel accelerometer sensor was placed in the anterior neck skin (transcutaneous) or postcricoid area. Stimulus thresholds, amplitude, and latency of laryngeal twitching measured using the accelerometer sensor were compared to those measured through EMG of the vocalis muscle.

Results.

The amplitudes of the accelerometer sensor at the anterior neck and postcricoid area were significantly lower than those of EMG because of differences in the measurement method used to evaluate laryngeal movement. However, no significant differences in stimulus thresholds between the EMG endotracheal tube and transcutaneous or postcricoid accelerometer sensors were observed.

Conclusion.

Accelerometer sensors located at the anterior neck or postcricoid area were able to identify laryngeal twitching. The stimulus intensity measured with these sensors was equivalent to that from conventional vocalis EMG. Our novel IONM system with an accelerometer sensor that checks changes in surface acceleration can be an alternative to EMG of the vocalis muscle for IONM in the future.

Assessment of the Safety of the New Hybrid Pencil Type Energy (NP) Device Used Close to the Recurrent Laryngeal Nerve in a Porcine Model: Comparison With a Conventional Electrosurgical Knife

BACKGROUND

Recurrent laryngeal nerve (RLN) paralysis is mainly associated with esophagectomy, and it may result in not only other morbidities, such as aspiration pneumonia, but also in long-term issues. Therefore, an approach to prevent RLN paralysis is necessary. The present study was designed to determine the technical usability of the new hybrid pencil type energy (NP) device developed by Olympus Corporation (Tokyo, Japan) and compare it with a conventional electrosurgical knife (EK) for resection around the RLN lymph nodes.

METHODS

This nonsurvival (acute) study included 10 pigs (20 RLNs) and investigated the threshold for thermal RLN damage with the NP device and a conventional EK. To obtain basic information for our study, a preliminary experiment for heat spread was performed.

RESULTS

When using the EK device, the amplitude value disappeared at a distance of 1 mm from the RLN, but when using the NP device, the amplitude value was maintained up to a distance of 0.5 mm. There were significant differences at distances of 0 mm, 0.5 mm, and 1 mm between the NP and EK devices. Furthermore, heat spread was lower with the NP device than with the EK device.

CONCLUSIONS

The new energy device developed by Olympus Corporation was found to be technically safe for resection of the RLN lymph nodes in a porcine model. To the best of our knowledge, this is the first study to demonstrate the potential advantages of using this new energy device in a clinical aspect.

Development of a Novel Intraoperative Neuromonitoring System Using a Surface Pressure Sensor to Detect Muscle Movement: A Rabbit Model Study

OBJECTIVES

False-negative or false-positive responses in intraoperative neuromonitoring (IONM) using electromyography (EMG) in thyroid surgery pose a challenge. Therefore, we developed a novel IONM system that uses a surface pressure sensor instead of EMG to detect muscle twitching. This study aimed to investigate the feasibility and safety of a new IONM system using a piezo-electric surface pressure sensor in an experimental animal model.

METHODS

We developed the surface pressure sensor by modifying a commercial piezo-electric sensor. We evaluated the stimulus thresholds to detect muscle movement, as well as the amplitude and latency of the EMG and surface pressure sensor in six sciatic nerves of three rabbits, according to the stimulus intensity.

RESULTS

The surface pressure sensor detected the muscle movements in response to a 0.1 mA stimulation of all six sciatic nerves. There were no differences in the thresholds of stimulus intensity between the surface pressure sensor and EMG recordings to detect muscle movements.

CONCLUSION

It is possible to measure the change in surface pressure by using a piezo-electric surface pressure sensor instead of EMG to detect muscle movement induced by nerve stimulation. The application of IONM using a piezo-electric surface pressure sensor during surgery is noninvasive, safe, and feasible. Measuring muscle twitching to identify the state of the nerves using the novel IONM system can be an alternative to recording of EMG responses.