2025 Pediatric Surgery Update Course - Nerve Monitoring and Stimulation in Pediatric Surgery

A 1.1 centimeter thyroid nodule that is TIRADS 4 with Bethesda 3 FNA (atypia of undetermined significance) has approximately 30% risk of cancer

The 2015 pediatric thyroid guidelines recommend surgery be performed by a high volume thyroid surgeon, defined as performing 30 thyroid surgeries per year

Lobectomy for pediatric thyroid nodules is recommended rather than molecular testing or repeat FNA currently because there is a higher rate of malignancy in pediatric populations compared to adults

One recent study showed recurrent laryngeal nerve injury rates decreased from 8% to 1.5% with nerve monitoring

In a recent survey, approximately 80% of pediatric thyroid surgeons use nerve monitoring

Studies in adults have shown nerve monitoring may help identify the nerve but may not change injury rates

The rate of recurrent laryngeal nerve injury in children is 9% versus about 6% in adults

Expense is one consideration for not using nerve monitoring, and some argue if it doesn't change injury rates there may be no reason to use it

In pediatric patients, devices may not have been small enough to monitor nerves, with some publications showing monitoring attempted down to age 4-5, and recent adhesive electrode publications showing use down to age zero

Adhesive electrodes can now be placed on a 3.0 ET tube, making intraoperative nerve monitoring available for almost all pediatric thyroid surgeries

Nerve monitoring may be most beneficial when doing total thyroidectomy where the contralateral cord is paralyzed, to help decrease risk of tracheostomy with bilateral paralysis

If nerve monitoring shows changes on one side during total thyroidectomy, this might lead the surgeon to delay and do the other side later

TIRADS was developed for adults to risk stratify nodules based on ultrasound imaging characteristics, and there has been caution against using it for pediatrics

If a child is too small for a 5.0 tube, the electrodes come separately and can be placed via direct laryngoscopy directly into the vocalis muscle for monitoring

The modified PEDS TIRADS recommends biopsy for every TIRADS 3 nodule over 1.5 centimeters, and using these restricted criteria based on size relative to patient size, no malignancies were missed

In a sacral nerve stimulator trial for children with fecal incontinence, the rate of wearing a diaper during the day decreased from 19% to 2%, and at nighttime decreased from 33% to 11%

Sacral nerve stimulation is not FDA approved in children

A Cochrane Review in adults suggests sacral nerve stimulation can help with fecal incontinence

A retrospective cohort study with 70 patients showed improvement in involuntary daytime and nighttime bowel movement rates with sacral nerve stimulation

Side effects of sacral nerve stimulation include pain and neurological symptoms, and about 40% required re-operation within about three years for dead battery or replacement

The sacral nerve stimulator is placed through the third sacral foramen and sends signals to the sacral nerves, with a trial period of a couple weeks before permanent implantation

Kids with urinary incontinence tend to respond pretty well to sacral nerve stimulation, learning from adults where urologists place these for urologic indications

For children with hypoventilation due to central hypoventilation syndromes, spinal cord injury, ALS, or metabolic disorders, diaphragm pacing is an option that has been able to avoid tracheostomy in some patients or help wean patients off ventilation

Diaphragm pacing can be done via phrenic nerve stimulation or direct diaphragm stimulation with leads implanted in the diaphragm

Diaphragm pacing was invented by Ray Anders in Cleveland and was used on Christopher Reeve