Objective: To investigate whether intraoperative neuromonitoring (IONM) has a significant advantage in reducing the incidence of recurrent laryngeal nerve (RLN) injury. Methods: Patients who underwent thyroid and parathyroid surgery from October 2012 to December 2017 at the Center for Thyroid and Breast Surgery of Xuanwu Hospital were retrospectively analyzed. They were divided into the IONM group and visualization alone group (VA group) according to whether IONM was used. Results: In total, 1696 nerves at risk of injury (IONM group, n = 1104; VA group, n = 592) were included in the analysis. Among the high-risk nerves, permanent damage occurred in no cases in the IONM group but in one case in the VA group. Because the higher proportion of central lymph node metastasis caused difficulties in central cervical lymph node dissection and identification of the RLN, the patients undergoing lateral cervical lymph node dissection in the VA group had a significantly higher risk of postoperative RLN injury (11.76% vs. 0.00%). Conclusion: IONM technology has advantages in protection of the RLN, especially in high-risk nerves and patients with a high proportion of central lymph node metastasis who require central and lateral cervical lymph node dissection. © The Author(s) 2020.