Critical Nerves to Preserve During Neck Dissection

Primary Nerve Preservation Principles

The National Comprehensive Cancer Network recommends preserving the structure and function of major cranial nerves, including CN VII, CN X, CN XI, and CN XII, even if adequate tumor margins are not achieved, recognizing that the surgeon should leave no gross residual disease 1, 2, 3, 4
If a nerve is functioning preoperatively, preserve the nerve at all costs, accepting closer margins if necessary, with adjuvant postoperative radiation or chemoradiation to address microscopic residual disease, as suggested by the National Comprehensive Cancer Network 1, 2, 3
If a nerve shows preoperative paralysis or direct tumor invasion, segmental resection and sometimes nerve grafting may be warranted at the surgeon's discretion if tumor-free margins are assured throughout the remainder of the procedure, according to the National Comprehensive Cancer Network 1, 2, 3

Routine recurrent nerve visualization and dissection is the surgical cornerstone for reducing nerve palsy during neck procedures involving thyroid or parathyroid regions, as stated by the International Journal of Surgery 5, 6
Complete visualization and nerve dissection from thoracic inlet to larynx is the gold standard, and avoid blind ligatures or coagulation, especially in the tracheoesophageal groove, as recommended by the International Journal of Surgery 6
The area near Berry's ligament and tubercle of Zuckerkandl represents the highest risk zone where most lesions occur, and use intermittent rather than continuous traction to prevent injury from excessive tension, as suggested by the International Journal of Surgery 6
Prophylactic or therapeutic neck dissection increases the risk of RLN injury and should be reserved for referral centers, according to the International Journal of Surgery 6

Continuous traction is the main cause of nerve injury, and anatomical variations including nerve distortion by large goiters, precocious division of extralaryngeal branches, and intertwining between neural and arterial branches must be anticipated, as stated by the International Journal of Surgery 6
Neck dissection with lymph node clearance increases the risk of definitive and transient unintentional nerve injuries, as reported by the International Journal of Surgery 6

The operative dictation must include details of nerve identification and preservation status, and the neck dissection should be oriented or sectioned to identify levels of lymph nodes encompassed, as recommended by the National Comprehensive Cancer Network 1, 2, 3