Does the right-sided approach in anterior cervical spine surgery increase the risk of recurrent laryngeal nerve injury?: a narrative review

Recurrent laryngeal nerve (RLN) injury is a recognized complication of anterior cervical spine surgery with potential for significant morbidity. Temporary vocal fold dysfunction is relatively common, whereas permanent deficit is uncommon. Theoretically, right-sided approaches carry a higher risk of RLN injury due to the shorter and more oblique course of the right RLN. This review aimed to determine whether the side of the surgical approach significantly influences the incidence of RLN injury. A comprehensive search of MEDLINE (Ovid), EMBASE, Scopus, and Google Scholar identified studies reporting RLN injury incidence and the surgical approach side. Owing to marked heterogeneity in study design and outcome reporting, a narrative review with limited statistical analysis was performed. Twenty-nine studies involving 13,540 anterior cervical procedures were included. The overall incidence of RLN injury was 2%, with no significant difference between left and right-sided approaches. However, 20 of 29 studies assessed RLN function only in symptomatic patients (reactive laryngoscopy), whereas nine studies performed postoperative laryngoscopy in all patients, regardless of symptoms (routine laryngoscopy). In this latter group, right-sided approaches were associated with a significantly higher incidence of RLN injury (odds ratio, 0.47; 95% confidence interval, 0.28-0.81; p=0.05). This review demonstrates that right-sided approaches are associated with a greater risk of RLN injury, although many injuries are minimally symptomatic or asymptomatic. Left-sided approaches should be preferred when feasible, considering factors such as surgeon handedness, training, and spinal pathology. Pre- and postoperative laryngoscopy are recommended in patients with a history of prior neck surgery.