Radical neck dissection is a common procedure we perform in the Head & Neck Surgery Department of the Portuguese Oncology Institute of Coimbra. Thyroid cancer is the most frequent diagnosis, followed by skin cancer of the head and neck (e.g. squamous cell carcinoma). This is a difficult surgical procedure that has changed over the last few years.
Possible complications following a radical neck dissection include voice changes and difficulty in swallowing (RLN injury), lymphatic leak (thoracic duct injury), impaired shoulder and arm movements (brachial plexus injury), sensory changes of the ear and skin (great auricular nerve injury), neck pain and weakness of the shoulder (spinal accessory nerve injury), vascular injury and wound infection.
Classic radical neck dissection includes the removal of the sternocleidomastoid muscle (SCM), the spinal accessory nerve (SAN - CN XI), and the internal jugular vein (IJV). Nowadays, surgery has moved towards less invasive procedures with preservation of those structures, while offering the same oncologic results. Modified radical neck dissection can be divided into three types depending on which structures are preserved (SCM, SAN, IJV) while resecting cervical lymph nodes from levels I to V:
Type I - preservation of one structure, usually the SAN
Type II - preservation of two structures, usually the SAN and the IJV
Type III - preservation of the three structures (SAN, IJV, SCM)
Selective cervical neck dissections are even less invasive, offering good oncologic results with less morbidity. The most frequently used is the selective lateral neck dissection, usually for thyroid cancer. This type of selective dissection removes lymph nodes from levels II (eventually only IIA), III, and IV. Since we perform this dissection usually for thyroid cancer, a level VI dissection is also included. For skin cancer of the head and neck with lymph node metastasis, a selective supraomohyoid neck dissection to remove lymph nodes from levels I, II, and III, is usually indicated. These less invasive neck dissections reflect the most frequently affected lymph nodes according to the responsible oncological disease. The less invasiveness but with good oncological outcomes is associated with less morbidity.
Important to remember that lateral neck dissection is indicated only after pathological confirmation by percutaneous biopsy. There is no place for prophylactic lateral neck dissection.
I would like to share with you two pictures of a bilateral neck dissection because of skin cancer. On the right side, we had to remove the SCM and the SAN because of tumor invasion. This was a challenging procedure aiming at promoting tumor burden reduction for the best adjuvant therapy response. Unfortunately it was a R2 dissection because of cranial bone envolvement.
Neck dissection is still “raw” surgery within an area with important vascular and nerve structures, for surgeons with good and “wild” surgical skills, who enjoy “playing” with Metzenbaum scissors while performing old-school precise dissections.
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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