The 'Safe-First' approach to identifying the recurrent laryngeal nerve in scarred necks of cervical spine surgery patients: A case series

Injury to the recurrent laryngeal nerve (RLN) is a recognized approach-related complication of anterior cervical spine surgery, and the risk rises in the scarred, reoperative neck. We describe a 'safe-first' approach in which dissection begins at a clean, unscarred caudal landmark, the nerve is first identified in virgin lower-neck tissue - looping beneath the subclavian artery on the right or ascending near the tracheoesophageal groove on the left - and then traced retrogradely to its laryngeal entry point, with endotracheal electromyography (EMG) for real-time mapping. Between 2015 and 2025, the approach was used in 89 patients (78 primary, 11 revision anterior cervical surgery). The RLN was identified in all. Two patients (2.2%) developed transient partial vocal cord palsy, confirmed on laryngoscopy, and recovered within 2 months; no permanent palsy occurred. A landmark-first routine with EMG monitoring may improve safety in scarred necks.