Neuromonitoring in thyroid surgery: attitudes, usage patterns, and predictors of use among endocrine surgeons

The use of neuromonitoring in thyroid surgery is controversial. Attitudes about neuromonitoring, usage patterns, and predictors of use have not been formally studied. We hypothesized that attitudes would predict usage patterns and that the predominant strategy among endocrine surgeons would be no neuromonitoring during thyroid surgery.

Members of the American Association of Endocrine Surgeons and registrants of the 2006 annual meeting were surveyed by e-mail. An Internet-based survey composed of simple answer and Likert questions was used. Central tendency was evaluated by modal response. Significance was analyzed by the chi-squared test, and strength of association was calculated by Cramér's V.

A total of 117 surveys were completed (41%). Respondents were placed into two groups based on use (37.1%), or nonuse (62.9%) of neuromonitoring. The use category was composed of routine (13.8%) and selective (23.3%) users. The nonuse category was composed of those who have never used neuromonitoring (49.1%) and those who have abandoned its use (13.8%). Nonusers were older (p = 0.023) and reported a lower case volume (p = 0.003), less familiarity with the technology (p < 0.001), and less access to the equipment (p < 0.001). Nonusers reported a lower frequency of patient-initiated discussions about neuromonitoring (p < 0.001) and were less likely to initiate a discussion with patients (p < 0.001). In total, 56% of users and 90% of nonusers believed neuromonitoring does not improve the safety of thyroidectomy (p < 0.01). There was no difference in perceived nerve injury rate between users and nonusers. Users agreed that benefits include facilitating identification of the recurrent laryngeal nerve, facilitating resident education, improving patient outcomes, and decreasing liability risk, whereas nonusers disagreed with these statements. Nonusers believed that neuromonitoring can lead to reliance on technology and loss of surgical technique or judgment, but users disagreed. There was consensus of opinion that neuromonitoring allows identification of an intact nerve, can lead to a false sense of security, drives up costs, is beneficial in <10% of cases, does not shorten the length of the procedure, and does not prevent nerve injury.

Usage is associated with surgeon age, case volume, equipment availability and familiarity, beliefs about the degree of benefit, and frequency of patient or doctor initiated discussions.