Evidencia de la aplicabilidad de la neuromonitorización intermitente en cirugía de tiroides
DOI:
https://doi.org/10.30944/20117582.363Palabras clave:
glándula tiroides, tiroidectomía, nervio laríngeo recurrente, conducción nerviosa, monitorización intraoperatorio, factores de riesgoResumen
La tiroidectomía es la cirugía cervical más frecuente, con poca frecuencia de complicaciones. La frecuencia de lesión definitiva del nervio laríngeo recurrente es menor de 1 %, la de hipoparatiroidismo definitivo es de 1 a 2 % y la de hematoma cervical es de 0,5 %. La frecuencia de la lesión bilateral del nervio laríngeo recurrente que obliga a una traqueostomía, es inferior al 0,2 %. Desde hace más de una década aparecieron reportes del uso de la neuromonitorización intermitente, como una estrategia para disminuir aún más el riesgo de lesión del nervio laríngeo recurrente y del laríngeo superior. El objetivo de esta revisión es exponer la información disponible en pro o en contra del uso rutinario de la neuromonitorización intermitente en la cirugía de tiroides. En cinco de las seis revisiones sistemáticas, llegan a la conclusión de que no existen datos que demuestren que las lesiones definitivas del nervio laríngeo recurrente o el laríngeo superior, disminuyan con el uso rutinario de la neuromonitorización. La mayoría de los autores sugieren que los pacientes de alto riesgo de lesión del nervio serían los más beneficiados, pero la definición de alto riesgo es bastante heterogénea e indefinida. El uso del monitor ayuda poco en la toma de decisiones, específicamente cuando se pierde la señal, que es el objetivo con el cual se usa. Tampoco existen datos que demuestren que el uso del neuromonitor disminuya las demandas médico-legales.
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Referencias bibliográficas
1. Kahaly GJ, Dietlein M. Cost estimation of thyroid disorders in Germany. Thyroid. 2002;12:909-14.
https://doi.org/10.1089/105072502761016548
2. Christou N, Mathonnet M. Complications after total thyroidectomy. J Visc Surg. 2013;150:249-56.
https://doi.org/10.1016/j.jviscsurg.2013.04.003
3. Hauch A, Al-Qurayshi Z, Randolph G, Kandil E. Total thyroidectomy is associated with increased risk of complications for low- and high-volume surgeons. Ann Surg Oncol. 2014;21: 3844-52.
https://doi.org/10.1245/s10434-014-3846-8
4. Weiss A, Lee KC, Brumund KT, Chang DC, Bouvet M. Risk factors for hematoma after thyroidectomy: Results from the nationwide inpatient sample. Surgery. 2014;156:399-404.
https://doi.org/10.1016/j.surg.2014.03.015
5. Puzziello A, Rosato L, Innaro N, Orlando G, Avenia N, Perigli G, Hypocalcemia following thyroid surgery: Incidence and risk factors. A longitudinal multicenter study comprising 2,631 patients. Endocrine. 2014;47:537-42.
https://doi.org/10.1007/s12020-014-0209-y
6. Jeannon JP, Orabi AA, Bruch GA, Abdalsalam HA, Simo R. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: A systematic review. Int J Clin Pract. 2009;63:624-9.
https://doi.org/10.1111/j.1742-1241.2008.01875.x
7. Misono S, Merati AL. Evidence-based practice: Evaluation and management of unilateral vocal fold paralysis. Otolaryngol Clin North Am. 2012;45:1083-108.
https://doi.org/10.1016/j.otc.2012.06.011
8. Hvidegaard T, Vase P, Dalsgaard SC, Jorgensen K. Endolaryngeal devices for perioperative identification and functional testing of the recurrent nerve. Otolaryngol Head Neck Surg. 1984;92:292- 4.
https://doi.org/10.1177/019459988409200308
9. Maloney RW, Murcek BW, Steehler KW, Sibly D, Maloney RE. A new method for intraoperative recurrent laryngeal nerve monitoring. Ear Nose Throat J. 1994;73:30-3.
https://doi.org/10.1177/014556139407300108
10. Barczynski M, Konturek A, Cichon S. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg. 2009;96:240-6.
https://doi.org/10.1002/bjs.6417
11. Barczynski M, Konturek A, Stopa M, Hubalewska-Dydejczyk A, Nowak W. Intraoperative neuromonitoring of the recurrent laryngeal nerves may improve outcomes of surgery for well-differentiated thyroid cancer. Endokrynologia Polska. 2012;63:166.
https://doi.org/10.2478/v10035-011-0030-8
12. Prokopakis E, Kaprana A, Velegrakis S, Panagiotaki I, Chatzakis N, Iro H, et al. Intraoperative recurrent laryngeal nerve monitoring in revision thyroidectomy. Eur Arch Otorhinolaryngol. 2013;270:2521-4.
https://doi.org/10.1007/s00405-012-2338-3
13. Higgins TS, Gupta R, Ketcham AS, Sataloff RT, Wadsworth JT, Sinacori JT. Recurrent laryngeal nerve monitoring versus identification alone on post-thyroidectomy true vocal fold palsy: A meta-analysis. Laryngoscope. 2011;121:1009-17.
https://doi.org/10.1002/lary.21578
14. Sanabria A, Ramírez A, Kowalski LP, Silver CE, Shaha AR, Owen RP, et al. Neuromonitoring in thyroidectomy. A meta-analysis of effectiveness from randomized controlled trials. Eur Arch Otorhinolaryngol. 2013; 270:2175-89
https://doi.org/10.1007/s00405-013-2557-2
15. Zheng S, Xu Z, Wei Y, Zeng M, He J. Effect of intraoperative neuromonitoring on recurrent laryngeal nerve palsy rates after thyroid surgery-A meta-analysis. J Formos Med Assoc. 2012;112:463-72. doi: 10.1016/j.jfma.2012.03.003. Epub 2012 Sep 7.
https://doi.org/10.1016/j.jfma.2012.03.003
16. Pisanu A, Porceddu G, Podda M, Cois A, Uccheddu A. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res. 2014;188:152-61.
https://doi.org/10.1016/j.jss.2013.12.022
17. Rulli F, Ambrogi V, Dionigi G, Amirhassankhani S, Mineo T, Ottaviani F, et al. Meta-analysis of recurrent laryngeal nerve injury in thyroid surgery with or without intraoperative nerve monitoring. Acta Otorhinolaryngol Ital. 2014;34:223-9.
18. Pardal-Refoyo JL, Ochoa-Sangrador C. Lesión bilateral del nervio laríngeo recurrente en tiroidectomía total con o sin neuromonitorización intraoperatoria. Revisión sistemática y metaanálisis. Acta Otorrinolaringol Esp. 2015; En prensa
https://doi.org/10.1016/j.otorri.2015.02.001
19. Dueñas JP, Duque CS. Monitorización intraoperatoria de los nervios laríngeos superior e inferior en cirugía de tiroides y paratiroides. Rev Colomb Cirugía. 2012;27:298-305.
20. Chiang FY, Lu IC, Tsai CJ, Hsiao PJ, Hsu CC, Wu CW. Does extensive dissection of recurrent laryngeal nerve during thyroid operation increase the risk of nerve injury? Evidence from the application of intraoperative neuromonitoring. Otolaryngol Head Neck Surg. 2011;32:499-503.
https://doi.org/10.1016/j.amjoto.2010.11.001
21. Atallah I, Dupret A, Carpentier AS, Weingertner AS, Volkmar PP, Rodier JF. Role of intraoperative neuromonitoring of the recurrent laryngeal nerve in high-risk thyroid surgery. J Otolaryngol Head Neck Surg. 2009;38:613-8.
22. Hermann M, Hellebart C, Freissmuth M. Neuromonitoring in thyroid surgery: Prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury. Ann Surg. 2004;240:9-17.
https://doi.org/10.1097/01.sla.0000132260.34503.02
23. Bahl M, Sosa JA, Nelson RC, Esclamado RM, Choudhury KR, Hoang JK. Trends in incidentally identified thyroid cancers over a decade: A retrospective analysis of 2,090 surgical patients. World J Surg. 2014;38:1312-7.
https://doi.org/10.1007/s00268-013-2407-9
24. Bilimoria KY, Bentrem DJ, Linn JG, Freel A, Yeh JJ, Stewart AK, et al. Utilization of total thyroidectomy for papillary thyroid cancer in the United States. Surgery. 2007;142:906-13.
https://doi.org/10.1016/j.surg.2007.09.002
25. Mitchell I, Livingston EH, Chang AY, Holt S, Snyder WH 3rd, Lingvay I, et al. Trends in thyroid cancer demographics and surgical therapy in the United States. Surgery. 2007;142:823-8.
https://doi.org/10.1016/j.surg.2007.09.011
26. Vashishta R, Mahalingam-Dhingra A, Lander L, Shin EJ, Shah RK. Thyroidectomy outcomes: A national perspective. Otolaryngol Head Neck Surg. 2012;147:1027-34.
https://doi.org/10.1177/0194599812454401
27. Barczynski M, Konturek A, Stopa M, Cichon S, Richter P, Nowak W. Total thyroidectomy for benign thyroid disease: Is it really worthwhile? Ann Surg. 2011;254:724-9.
https://doi.org/10.1097/SLA.0b013e3182360118
28. Ciuni R, Biondi A, Di GM, Basile F, Ciuni S. Total thyroidectomy vs. subtotal thyroidectomy for plurinodular goiter. Analysis 1517 cases. Ann Ital Chir. 2010;81:9-12.
29. Efremidou EI, Papageorgiou MS, Liratzopoulos N, Manolas KJ. The efficacy and safety of total thyroidectomy in the management of benign thyroid disease: A review of 932 cases. Can J Surg. 2009;52:39-44.
30. Fagan TJ. Nomogram for Bayes theorem. N Engl J Med. 1975;293:257.
https://doi.org/10.1056/NEJM197507312930513
31. Timmermann W, Hamelmann WH, Thomusch O, Sekulla C, Grond S, Neumann HJ, et al. Effectiveness and results of intraoperative neuromonitoring in thyroid surgery. Statement of the interdisciplinary study group on intraoperative neuromonitoring of thyroid surgery. Chirurg. 2004;75:916-22.
https://doi.org/10.1007/s00104-004-0858-0
32. Sitges-Serra A, Fontane J, Duenas JP, Duque CS, Lorente L, Trillo L, et al. Prospective study on loss of signal on the first side during neuromonitoring of the recurrent laryngeal nerve in total thyroidectomy. Br J Surg. 2013;100:662-6.
https://doi.org/10.1002/bjs.9044
33. Sanabria A. Análisis económico de la neuromonitoría rutinaria del nervio laríngeo recurrente en tiroidectomía total. Congreso Nacional de Endocrinologia; 06/2012, 2012; Medellin, Colombia.
34. Angelos P. Recurrent laryngeal nerve monitoring: State of the art, ethical and legal issues. Surg Clin North Am. 2009;89:1157-69.
https://doi.org/10.1016/j.suc.2009.06.010
35. Angelos P. Ethical and medicolegal issues in neuromonitoring during thyroid and parathyroid surgery: A review of the recent literature. Curr Opin Oncol. 2012;24:16-21.
https://doi.org/10.1097/CCO.0b013e32834cd596
36. Chung TK, Rosenthal EL, Porterfield JR, Carroll WR, Richman J, Hawn MT. Examining national outcomes after thyroidectomy with nerve monitoring. J Am Coll Surg. 2014;219:765-70.
https://doi.org/10.1016/j.jamcollsurg.2014.04.013
37. Chandrasekhar SS, Randolph GW, Seidman MD, Rosenfeld RM, Angelos P, Barkmeier-Kraemer J, et al. Clinical practice guideline: Improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg. 2013;148:S1-37.
https://doi.org/10.1177/0194599813487301
38. Chiang FY, Lee KW, Chen HC, Chen HY, Lu IC, Kuo WR, et al. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation. World J Surg. 2010;34:223-9.
https://doi.org/10.1007/s00268-009-0316-8
39. Draycott S, Dabbs A. Cognitive dissonance. 1: An overview of the literature and its integration into theory and practice in clinical psychology. Br J Clin Psychol. 1998;37(Pt 3):341-53.
https://doi.org/10.1111/j.2044-8260.1998.tb01390.x
40. Munro GD, Stansbury JA. The dark side of self-affirmation: Confirmation bias and illusory correlation in response to threatening information. Pers Soc Psychol Bull. 2009;35:1143-53.
https://doi.org/10.1177/0146167209337163
41. Miles RW. Fallacious reasoning and complexity as root causes of clinical inertia. J Am Med Dir Assoc. 2007;8:349-54.
https://doi.org/10.1016/j.jamda.2007.05.003
42. Cook A, Arndt J, Lieberman JD. Firing back at the backfire effect: The influence of mortality salience and nullification beliefs on reactions to inadmissible evidence. Law Hum Behav. 2004;28:389- 410.
https://doi.org/10.1023/B:LAHU.0000039332.21386.f4
https://doi.org/10.1089/105072502761016548
2. Christou N, Mathonnet M. Complications after total thyroidectomy. J Visc Surg. 2013;150:249-56.
https://doi.org/10.1016/j.jviscsurg.2013.04.003
3. Hauch A, Al-Qurayshi Z, Randolph G, Kandil E. Total thyroidectomy is associated with increased risk of complications for low- and high-volume surgeons. Ann Surg Oncol. 2014;21: 3844-52.
https://doi.org/10.1245/s10434-014-3846-8
4. Weiss A, Lee KC, Brumund KT, Chang DC, Bouvet M. Risk factors for hematoma after thyroidectomy: Results from the nationwide inpatient sample. Surgery. 2014;156:399-404.
https://doi.org/10.1016/j.surg.2014.03.015
5. Puzziello A, Rosato L, Innaro N, Orlando G, Avenia N, Perigli G, Hypocalcemia following thyroid surgery: Incidence and risk factors. A longitudinal multicenter study comprising 2,631 patients. Endocrine. 2014;47:537-42.
https://doi.org/10.1007/s12020-014-0209-y
6. Jeannon JP, Orabi AA, Bruch GA, Abdalsalam HA, Simo R. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: A systematic review. Int J Clin Pract. 2009;63:624-9.
https://doi.org/10.1111/j.1742-1241.2008.01875.x
7. Misono S, Merati AL. Evidence-based practice: Evaluation and management of unilateral vocal fold paralysis. Otolaryngol Clin North Am. 2012;45:1083-108.
https://doi.org/10.1016/j.otc.2012.06.011
8. Hvidegaard T, Vase P, Dalsgaard SC, Jorgensen K. Endolaryngeal devices for perioperative identification and functional testing of the recurrent nerve. Otolaryngol Head Neck Surg. 1984;92:292- 4.
https://doi.org/10.1177/019459988409200308
9. Maloney RW, Murcek BW, Steehler KW, Sibly D, Maloney RE. A new method for intraoperative recurrent laryngeal nerve monitoring. Ear Nose Throat J. 1994;73:30-3.
https://doi.org/10.1177/014556139407300108
10. Barczynski M, Konturek A, Cichon S. Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg. 2009;96:240-6.
https://doi.org/10.1002/bjs.6417
11. Barczynski M, Konturek A, Stopa M, Hubalewska-Dydejczyk A, Nowak W. Intraoperative neuromonitoring of the recurrent laryngeal nerves may improve outcomes of surgery for well-differentiated thyroid cancer. Endokrynologia Polska. 2012;63:166.
https://doi.org/10.2478/v10035-011-0030-8
12. Prokopakis E, Kaprana A, Velegrakis S, Panagiotaki I, Chatzakis N, Iro H, et al. Intraoperative recurrent laryngeal nerve monitoring in revision thyroidectomy. Eur Arch Otorhinolaryngol. 2013;270:2521-4.
https://doi.org/10.1007/s00405-012-2338-3
13. Higgins TS, Gupta R, Ketcham AS, Sataloff RT, Wadsworth JT, Sinacori JT. Recurrent laryngeal nerve monitoring versus identification alone on post-thyroidectomy true vocal fold palsy: A meta-analysis. Laryngoscope. 2011;121:1009-17.
https://doi.org/10.1002/lary.21578
14. Sanabria A, Ramírez A, Kowalski LP, Silver CE, Shaha AR, Owen RP, et al. Neuromonitoring in thyroidectomy. A meta-analysis of effectiveness from randomized controlled trials. Eur Arch Otorhinolaryngol. 2013; 270:2175-89
https://doi.org/10.1007/s00405-013-2557-2
15. Zheng S, Xu Z, Wei Y, Zeng M, He J. Effect of intraoperative neuromonitoring on recurrent laryngeal nerve palsy rates after thyroid surgery-A meta-analysis. J Formos Med Assoc. 2012;112:463-72. doi: 10.1016/j.jfma.2012.03.003. Epub 2012 Sep 7.
https://doi.org/10.1016/j.jfma.2012.03.003
16. Pisanu A, Porceddu G, Podda M, Cois A, Uccheddu A. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res. 2014;188:152-61.
https://doi.org/10.1016/j.jss.2013.12.022
17. Rulli F, Ambrogi V, Dionigi G, Amirhassankhani S, Mineo T, Ottaviani F, et al. Meta-analysis of recurrent laryngeal nerve injury in thyroid surgery with or without intraoperative nerve monitoring. Acta Otorhinolaryngol Ital. 2014;34:223-9.
18. Pardal-Refoyo JL, Ochoa-Sangrador C. Lesión bilateral del nervio laríngeo recurrente en tiroidectomía total con o sin neuromonitorización intraoperatoria. Revisión sistemática y metaanálisis. Acta Otorrinolaringol Esp. 2015; En prensa
https://doi.org/10.1016/j.otorri.2015.02.001
19. Dueñas JP, Duque CS. Monitorización intraoperatoria de los nervios laríngeos superior e inferior en cirugía de tiroides y paratiroides. Rev Colomb Cirugía. 2012;27:298-305.
20. Chiang FY, Lu IC, Tsai CJ, Hsiao PJ, Hsu CC, Wu CW. Does extensive dissection of recurrent laryngeal nerve during thyroid operation increase the risk of nerve injury? Evidence from the application of intraoperative neuromonitoring. Otolaryngol Head Neck Surg. 2011;32:499-503.
https://doi.org/10.1016/j.amjoto.2010.11.001
21. Atallah I, Dupret A, Carpentier AS, Weingertner AS, Volkmar PP, Rodier JF. Role of intraoperative neuromonitoring of the recurrent laryngeal nerve in high-risk thyroid surgery. J Otolaryngol Head Neck Surg. 2009;38:613-8.
22. Hermann M, Hellebart C, Freissmuth M. Neuromonitoring in thyroid surgery: Prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury. Ann Surg. 2004;240:9-17.
https://doi.org/10.1097/01.sla.0000132260.34503.02
23. Bahl M, Sosa JA, Nelson RC, Esclamado RM, Choudhury KR, Hoang JK. Trends in incidentally identified thyroid cancers over a decade: A retrospective analysis of 2,090 surgical patients. World J Surg. 2014;38:1312-7.
https://doi.org/10.1007/s00268-013-2407-9
24. Bilimoria KY, Bentrem DJ, Linn JG, Freel A, Yeh JJ, Stewart AK, et al. Utilization of total thyroidectomy for papillary thyroid cancer in the United States. Surgery. 2007;142:906-13.
https://doi.org/10.1016/j.surg.2007.09.002
25. Mitchell I, Livingston EH, Chang AY, Holt S, Snyder WH 3rd, Lingvay I, et al. Trends in thyroid cancer demographics and surgical therapy in the United States. Surgery. 2007;142:823-8.
https://doi.org/10.1016/j.surg.2007.09.011
26. Vashishta R, Mahalingam-Dhingra A, Lander L, Shin EJ, Shah RK. Thyroidectomy outcomes: A national perspective. Otolaryngol Head Neck Surg. 2012;147:1027-34.
https://doi.org/10.1177/0194599812454401
27. Barczynski M, Konturek A, Stopa M, Cichon S, Richter P, Nowak W. Total thyroidectomy for benign thyroid disease: Is it really worthwhile? Ann Surg. 2011;254:724-9.
https://doi.org/10.1097/SLA.0b013e3182360118
28. Ciuni R, Biondi A, Di GM, Basile F, Ciuni S. Total thyroidectomy vs. subtotal thyroidectomy for plurinodular goiter. Analysis 1517 cases. Ann Ital Chir. 2010;81:9-12.
29. Efremidou EI, Papageorgiou MS, Liratzopoulos N, Manolas KJ. The efficacy and safety of total thyroidectomy in the management of benign thyroid disease: A review of 932 cases. Can J Surg. 2009;52:39-44.
30. Fagan TJ. Nomogram for Bayes theorem. N Engl J Med. 1975;293:257.
https://doi.org/10.1056/NEJM197507312930513
31. Timmermann W, Hamelmann WH, Thomusch O, Sekulla C, Grond S, Neumann HJ, et al. Effectiveness and results of intraoperative neuromonitoring in thyroid surgery. Statement of the interdisciplinary study group on intraoperative neuromonitoring of thyroid surgery. Chirurg. 2004;75:916-22.
https://doi.org/10.1007/s00104-004-0858-0
32. Sitges-Serra A, Fontane J, Duenas JP, Duque CS, Lorente L, Trillo L, et al. Prospective study on loss of signal on the first side during neuromonitoring of the recurrent laryngeal nerve in total thyroidectomy. Br J Surg. 2013;100:662-6.
https://doi.org/10.1002/bjs.9044
33. Sanabria A. Análisis económico de la neuromonitoría rutinaria del nervio laríngeo recurrente en tiroidectomía total. Congreso Nacional de Endocrinologia; 06/2012, 2012; Medellin, Colombia.
34. Angelos P. Recurrent laryngeal nerve monitoring: State of the art, ethical and legal issues. Surg Clin North Am. 2009;89:1157-69.
https://doi.org/10.1016/j.suc.2009.06.010
35. Angelos P. Ethical and medicolegal issues in neuromonitoring during thyroid and parathyroid surgery: A review of the recent literature. Curr Opin Oncol. 2012;24:16-21.
https://doi.org/10.1097/CCO.0b013e32834cd596
36. Chung TK, Rosenthal EL, Porterfield JR, Carroll WR, Richman J, Hawn MT. Examining national outcomes after thyroidectomy with nerve monitoring. J Am Coll Surg. 2014;219:765-70.
https://doi.org/10.1016/j.jamcollsurg.2014.04.013
37. Chandrasekhar SS, Randolph GW, Seidman MD, Rosenfeld RM, Angelos P, Barkmeier-Kraemer J, et al. Clinical practice guideline: Improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg. 2013;148:S1-37.
https://doi.org/10.1177/0194599813487301
38. Chiang FY, Lee KW, Chen HC, Chen HY, Lu IC, Kuo WR, et al. Standardization of intraoperative neuromonitoring of recurrent laryngeal nerve in thyroid operation. World J Surg. 2010;34:223-9.
https://doi.org/10.1007/s00268-009-0316-8
39. Draycott S, Dabbs A. Cognitive dissonance. 1: An overview of the literature and its integration into theory and practice in clinical psychology. Br J Clin Psychol. 1998;37(Pt 3):341-53.
https://doi.org/10.1111/j.2044-8260.1998.tb01390.x
40. Munro GD, Stansbury JA. The dark side of self-affirmation: Confirmation bias and illusory correlation in response to threatening information. Pers Soc Psychol Bull. 2009;35:1143-53.
https://doi.org/10.1177/0146167209337163
41. Miles RW. Fallacious reasoning and complexity as root causes of clinical inertia. J Am Med Dir Assoc. 2007;8:349-54.
https://doi.org/10.1016/j.jamda.2007.05.003
42. Cook A, Arndt J, Lieberman JD. Firing back at the backfire effect: The influence of mortality salience and nullification beliefs on reactions to inadmissible evidence. Law Hum Behav. 2004;28:389- 410.
https://doi.org/10.1023/B:LAHU.0000039332.21386.f4
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2015-01-01
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Sanabria , Álvaro. Evidencia De La Aplicabilidad De La neuromonitorización Intermitente En cirugía De Tiroides. Rev Colomb Cir 2015, 30, 220-229.
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