Preventing recurrent laryngeal nerve injury in thyroidectomy: the role of continuous vagal monitoring

Recurrent laryngeal nerve (RLN) injury remain the most serious complication of thyroidectomy, particularly in high-risk cases involving reoperations, malignancy, or complex anatomy. Continuous intraoperative neuromonitoring (C-IONM) offers real-time nerve stimulation and electromographic feedback, enabling early detection of nerve stress and prevention of irreversible damage. This systematic review evaluates the efficacy, predictive accuracy, and clinical impact of C-IONM in reducing RLN injury during high-risk thyroid surgery. While bread population studies show limited benefit over visual identification or intermittent monitoring, targeted analyses reveal that C-IONM significantly lowers the incidence of permanent RLN injury in complex procedures. Its high negative predictive value supports safe surgical staging to prevent bilateral vocal cord palsy, transforming intraoperative strategy and elevating standards of care. Despite technical challenges and modest setup time, C-IONM demonstrates a favorable safety profile and cost-effectiveness when applied to high-risk cohorts. Adherence to standardized protocols from the International Neural Monitoring Study Group is essential for optimal outcomes. C-IONM should be considered a necessary adjunct in high-risk thyroidectomy, with future randomized trials needed to further quantify its impact.