In 1906, George Crile described the classical radical neck dissection (RND). It was the primary operation for surgical management of metastatic cervical lymph nodes for many decades. Starting in the late 1960s and later, Bocca and Pignataro, O. Suarez, Ballantyne, Jesse, and Suen began to describe modifications of the RND and demonstrated that the control and cure rates were equal to the RND.

The technique of the modified radical neck dissection (MRND) includes removal of all cervical node levels (I, II, III, IV, and V) (Fig. 4.1) with preservation of one or more of the following: the spinal accessory nerve, the sternocleidomastoid muscle (SCM), and the internal jugular vein (IJV).

Cancer in the neck may represent either a primary cancer or metastasis from a cancer usually primary in the upper aerodigestive tract or the skin of the face or neck. Primary cancers in the neck arise from the tail of the parotid gland, the thyroid, the submandibular gland. Lymphoma is frequently encountered in the neck.

Other sites to consider that can metastasize to the neck include lungs, breast, cervix, prostate, and other intra-abdominal organs.

A complete examination of the head and neck must be performed. The location of the enlarged nodes can guide you to the primary site. It is important to check the thyroid gland for nodules.

The size, number, and mobility of the lymph nodes are important to note. Fixation to the skin or underlying structures may be a contraindication to this procedure.

1. Life expectancy of <3 months

2. Uncontrollable cancer at the primary site

3. Lymph nodes fixed deeply and unchanged by irradiation and/or chemotherapy

4. Surgeon who is inexperienced with the MRND

The MRND should remove essentially the same lymph nodes as an RND (Fig. 4.2). The SCM is in the middle of the dissection and makes the surgery more difficult. The SCM can be divided at the inferior attachment to the clavicle to make the surgery easier, or it could be resected with the lymph nodes. The SCM muscle should be removed if tumor is adherent to it or invading into it.

An incision should be planned so that all the lymph nodes can be accessed. My preference is a “hockeystick” incision. This incision begins at the mastoid tip and should be carried almost straight down to just above the clavicle; the incision should be curved medially to the midline. Before I start the incision, I place scratch marks, with a knife, on each side of the incision mark and place these at several spots. With a long incision, it is easier to match these points up for accurate closure of the skin.

The incision is usually made with a monopolar needle-tip cautery through the skin and dermis, then I switch to the blade-tip Bovie. The blade tip is useful for dissecting while in the off position. During the flap incision and elevation, I watch for the external jugular vein that can bleed significantly. This vein can be preserved or ligated.