What is Radical Neck Dissection?
Radical neck dissection is a historical surgical procedure that removes all cervical lymph node groups (levels I-V) along with the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve—though contemporary guidelines now prefer the term "comprehensive neck dissection" to describe removal of all nodal levels regardless of whether these non-lymphatic structures are preserved. 1
Historical Context and Evolution
Radical neck dissection (RND) was described by Crile in 1906 and became the gold standard for managing metastatic nodal disease in head and neck cancers 2. The procedure traditionally involved:
- Removal of all lymph node levels I through V 3
- Excision of the sternocleidomastoid muscle 3
- Removal of the internal jugular vein 3
- Sacrifice of the spinal accessory nerve 3
This extensive resection resulted in significant functional and cosmetic morbidity, including shoulder dysfunction from spinal accessory nerve loss 2, 4.
Contemporary Nomenclature Shift
The NCCN guidelines explicitly state that contemporary classification now uses "comprehensive" versus "selective" terminology rather than the older "radical" or "modified radical" designations. 1, 5
Key Distinction:
- Comprehensive neck dissection removes all lymph node groups that would be included in a classic radical neck dissection (levels I-V), but whether the sternocleidomastoid muscle, jugular vein, or spinal accessory nerve is preserved does not affect the "comprehensive" classification 1
- This represents a fundamental shift in thinking—the extent of lymphadenectomy defines the procedure, not the sacrifice of non-lymphatic structures 5
Current Clinical Applications
Comprehensive neck dissection (the modern equivalent of radical neck dissection) is specifically recommended for N3 disease in head and neck cancers. 1, 5
Indications by Nodal Stage:
- N0 disease: Selective neck dissection is typically recommended 1
- N1-N2 disease: Modified radical neck dissection (MRND) or comprehensive dissection may be appropriate 5
- N3 disease: Comprehensive neck dissection is the standard recommendation 1, 5
Site-Specific Considerations:
- Bilateral comprehensive dissection is often necessary for tumors at or near the midline or sites with bilateral drainage 1, 5
- Extended neck dissection may be required when disease involves structures beyond the standard dissection boundaries, particularly in N2 and N3 disease 6
Pathologic Requirements
A properly performed comprehensive/radical neck dissection should yield 10 or more lymph nodes for pathologic examination, compared to 6 or more for selective neck dissections. 5, 7
Important Clinical Caveats
- When performed as salvage after failed primary treatment, complication rates increase significantly, including delayed wound healing, skin necrosis, and carotid exposure 5
- Neck recurrence rates were historically higher with modified approaches in N2 and N3 cases (52% vs. 33% for standard RND), though overall survival remained equivalent 8
- The most difficult regions for local control include disease behind the mastoid process and involvement of subdermal lymphatics 6