Intraoperative neural monitoring (IONM) has emerged as a prominent adjunct in thyroidectomy intended to enhance the identification and preservation of the recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN). However, its role remains controversial. This chapter reviews the key debates surrounding IONM in thyroid surgery. We begin by introducing thyroid surgery complications related to nerve injury and the historical evolution of nerve monitoring from early experiments in the 1960s to modern widespread use. We then examine clinical efficacy data, contrasting studies that report reduced RLN palsy rates with IONM against those finding no significant difference. Issues of false-positive and false-negative signals are discussed, highlighting technical and interpretative challenges that can lead to either unnecessary alarm or missed injury. Economic considerations are explored, weighing the costs of nerve monitoring equipment and disposable electrodes against potential savings from avoided injury and litigation. The learning curve associated with IONM is addressed, emphasizing the need for surgeon training to realize its benefits. We analyze the impact of IONM on surgical strategy and outcomes, including its role in preventing bilateral vocal cord paralysis via staged procedures. Technological limitations of standard intermittent monitoring and advances like continuous vagal monitoring are described. Proper interpretation of electromyographic (EMG) signals and standardized protocols is reviewed as crucial for effective use. The chapter also discusses the unique challenges of monitoring the external branch of the superior laryngeal nerve (EBSLN) and its importance for voice outcomes. Medicolegal implications are considered in light of malpractice trends. In conclusion, we summarize the current consensus that IONM is a valuable adjunct but not a substitute for surgical expertise, and we outline future directions for research and technology to further improve nerve injury prevention in thyroid surgery.