http://www.intraoperativeneuromonitoring.com/

Intraoperative Neuromonitoring, Orlando, FL (2026)

05/28/2026

In IONM, "you should learn crani's" means you should learn/do more. But why not go for more?

(Yes, back on this again)

I already got some pushback last month on a similar post that it's not worth it.... mostly boiled down to effort, higher stakes, and $.

Some made the counter points of passion.

I made some points of building optionality in an unknown future.

But here's a third reason to continue to poke around, get your hands dirty, and help make improvements in all aspects of our job.

____________

We spend a lot of our lives at work and you don't always want things to be easy and familiar.

Future you wants you to mentally/emotionally struggle a bit. Just like it wants you to move heavy weights (or other forms of struggling physically).

Our DNA has been molded to survive in scarce resources and thrive with struggle.

We weren't built to live the life of a house cat, but one that needs to figure out what to eat, how to not get eaten, and make due with shelter.

Consider this:

The tamer the animal, the smaller the brain... domesticated animals had brains about 25% smaller than their wild forebears.

The first year of IONM is a mental struggle. The next 30 depends on how you go about it.

My advice: be the cat that eats the rat, not the canned kibble.

05/26/2026

Corticobulbar MEPs have come into favor for post-fossa surgery.

But what about blink reflexes? 😉

Like other reflexes, it has largely been abandoned due to the effects of anesthesia.

But corticobulbar MEPs aren't bulletproof, either. Stimulating centrally vs peripherally seems to be an ongoing complication. False positives with anesthetic fade are another concern.

In a small sample size, Aydinlar et all found utility in adding the blink response to their monitoring plan.

They were able to produce a case where the blink response demonstrated the change and corticobulbar MEPs were uneventful.

𝗪𝗵𝗮𝘁 𝘄𝗲𝗿𝗲 𝘁𝗵𝗲𝗶𝗿 𝘁𝗼𝘁𝗮𝗹 𝗳𝗶𝗻𝗱𝗶𝗻𝗴𝘀?

𝘈𝘤𝘤𝘰𝘳𝘥𝘪𝘯𝘨 𝘵𝘰 𝘰𝘶𝘳 𝘮𝘰𝘥𝘦𝘭, 𝘪𝘧 𝘢 𝘉𝘙 𝘸𝘢𝘴 𝘱𝘳𝘦𝘴𝘦𝘳𝘷𝘦𝘥, 𝘪𝘵 𝘱𝘳𝘦𝘥𝘪𝘤𝘵𝘦𝘥 𝘵𝘩𝘦 𝘱𝘢𝘵𝘪𝘦𝘯𝘵’𝘴 𝘰𝘶𝘵𝘤𝘰𝘮𝘦 𝘢𝘴 𝘯𝘰𝘳𝘮𝘢𝘭 𝘧𝘶𝘯𝘤𝘵𝘪𝘰𝘯–𝘮𝘰𝘥𝘦𝘳𝘢𝘵𝘦 𝘥𝘺𝘴𝘧𝘶𝘯𝘤𝘵𝘪𝘰𝘯; 𝘪𝘧 𝘱𝘦𝘳𝘮𝘢𝘯𝘦𝘯𝘵𝘭𝘺 𝘭𝘰𝘴𝘵, 𝘢𝘴 𝘴𝘦𝘷𝘦𝘳𝘦 𝘥𝘺𝘴𝘧𝘶𝘯𝘤𝘵𝘪𝘰𝘯–𝘵𝘰𝘵𝘢𝘭 𝘱𝘢𝘳𝘢𝘭𝘺𝘴𝘪𝘴 𝘪𝘯 𝘵𝘩𝘦 𝘱𝘰𝘴𝘵𝘰𝘱𝘦𝘳𝘢𝘵𝘪𝘷𝘦 𝘱𝘦𝘳𝘪𝘰𝘥 𝘸𝘪𝘵𝘩 0.75 𝘴𝘦𝘯𝘴𝘪𝘵𝘪𝘷𝘪𝘵𝘺, 1 𝘴𝘱𝘦𝘤𝘪𝘧𝘪𝘤𝘪𝘵𝘺, 𝘢𝘯𝘥
0.968 𝘢𝘤𝘤𝘶𝘳𝘢𝘤𝘺; 𝘢𝘯𝘥 𝘵𝘩𝘪𝘳𝘥-𝘮𝘰𝘯𝘵𝘩 𝘱𝘦𝘳𝘪𝘰𝘥 𝘸𝘪𝘵𝘩 1 𝘴𝘦𝘯𝘴𝘪𝘵𝘪𝘷𝘪𝘵𝘺, 1 𝘴𝘱𝘦𝘤𝘪𝘧𝘪𝘤𝘪𝘵𝘺, 𝘢𝘯𝘥 1 𝘢𝘤𝘤𝘶𝘳𝘢𝘤𝘺.

𝘚𝘪𝘮𝘪𝘭𝘢𝘳𝘭𝘺, 𝘸𝘩𝘦𝘯 𝘧𝘢𝘤𝘪𝘢𝘭 𝘊𝘰𝘔𝘌𝘗𝘴 𝘸𝘦𝘳𝘦 𝘱𝘳𝘦𝘴𝘦𝘳𝘷𝘦𝘥, 𝘰𝘶𝘳 𝘮𝘰𝘥𝘦𝘭 𝘢𝘯𝘵𝘪𝘤𝘪𝘱𝘢𝘵𝘦𝘴 𝘯𝘰𝘳𝘮𝘢𝘭 𝘧𝘶𝘯𝘤𝘵𝘪𝘰𝘯–𝘮𝘰𝘥𝘦𝘳𝘢𝘵𝘦 𝘥𝘺𝘴𝘧𝘶𝘯𝘤𝘵𝘪𝘰𝘯 𝘢𝘯𝘥, 𝘪𝘧 𝘭𝘰𝘴𝘵, 𝘴𝘦𝘷𝘦𝘳𝘦 𝘥𝘺𝘴𝘧𝘶𝘯𝘤𝘵𝘪𝘰𝘯–𝘵𝘰𝘵𝘢𝘭 𝘱𝘢𝘳𝘢𝘭𝘺𝘴𝘪𝘴 𝘰𝘵𝘩𝘦𝘳𝘸𝘪𝘴𝘦. 𝘐𝘵 𝘱𝘦𝘳𝘧𝘰𝘳𝘮𝘦𝘥 𝘸𝘪𝘵𝘩 0.937 𝘢𝘤𝘤𝘶𝘳𝘢𝘤𝘺, 0.5 𝘴𝘦𝘯𝘴𝘪𝘵𝘪𝘷𝘪𝘵𝘺, 𝘢𝘯𝘥 1 𝘴𝘱𝘦𝘤𝘪𝘧𝘪𝘤𝘪𝘵𝘺 𝘧𝘰𝘳 𝘵𝘩𝘦 𝘱𝘰𝘴𝘵𝘰𝘱𝘦𝘳𝘢𝘵𝘪𝘷𝘦 𝘱𝘦𝘳𝘪𝘰𝘥 𝘢𝘯𝘥 𝘸𝘪𝘵𝘩 0.968 𝘢𝘤𝘤𝘶𝘳𝘢𝘤𝘺, 0.667 𝘴𝘦𝘯𝘴𝘪𝘵𝘪𝘷𝘪𝘵𝘺, 𝘢𝘯𝘥 1 𝘴𝘱𝘦𝘤𝘪𝘧𝘪𝘤𝘪𝘵𝘺 𝘧𝘰𝘳 𝘵𝘩𝘦 𝘵𝘩𝘪𝘳𝘥-𝘮𝘰𝘯𝘵𝘩 𝘱𝘦𝘳𝘪𝘰𝘥.

Their recommendation is a further look at the utility of adding BR to your monitoring plan. It might just be a helpful complement.

𝗪𝗵𝗼 𝘄𝗮𝗻𝘁𝘀 𝘁𝗼 𝘀𝗵𝗮𝗿𝗲 𝘁𝗵𝗲𝗶𝗿 𝗲𝘅𝗽𝗲𝗿𝗶𝗲𝗻𝗰𝗲?

Intraoperative Neuromonitoring of Blink Reflex During Posterior Fossa Surgeries and Its Correlation With Clinical Outcome

05/21/2026

IONM to reduce pneumonia is a new one for me. Monitoring isn't something I have had the chance to do. Here are some highlights:

From the discussion:
Our study also revealed that IONM reduced the incidence of pneumonia. Postoperative pneumonia is the most common complication after esophagectomy, with an incidence of up to 60%. Several recent studies showed that RLNP is associated with pneumonia, and multivariate analysis showed that RLNP is the primary independent risk factor for pneumonia. (RR = 2.3–6.2). Our study supports the previous studies that IONM can reduce pneumonia by preventing RLNP. Although inconsistent with a previous meta-analysis, our results are more reliable due to the larger number of studies included and insignificant heterogeneity. A study suggests that RLNP is an independent prognostic factor for pneumonia and POHS. In addition, we found that IONM does not increase the operative time and the risk of other common complications, which reflected the feasibility of IONM.

From the conclusion:
Our meta-analysis demonstrated that the application of IONM during esophagectomy reduced the incidence of RLNP and pneumonia and was associated with more mediastinal and total LN dissected. In addition, IONM does not increase the incidence of aspiration, chylothorax, and anastomotic leakage and does not increase the total operative time or postoperative hospital stays. IONM should be recommended for esophagectomy.

Are there any surgeons looking into IONM's use case here?

05/19/2026

Is this part of your hashtag setup for a cervical spine case? For your consideration...

If I'm running tcMEP for a cervical spine case C5 or lower, I might add traps and consider that a control.

A control is helpful to see if metabolic conditions (anes protocol, BP, etc.) are causing global problems to the test we are running: tcMEP.

If it goes down/out, and so does everything else, we have to start with metabolic troubleshooting.

Since the innervation is most likely above the level of the surgery, it helps us determine those changes vs pathological.

But do the traps as a control make the best sense?

Here's an argument against it:

- Traps are not fine movers, so the amount of fibers innervated per alpha motor neuron is high. We might see greater loss of CMAPs with metabolic problems, resulting in a higher chance of false positives.

- In the US (similar trends globally), +40% of adults are obese. Intramuscular electrode position -- while also trying to keep it out of the surgical field -- might be difficult. That means worse CMAPs.

- Some positional concerns might stem from the upper cervical spine, making traps no longer part of a control group. Still helpful, just not in the manner you anticipated.

So, what other option do you have?

How about a muscle that is a fine mover, has almost no fat around it, and has a motor nucleus and muscle fiber location caudal enough from the stimulation site to have lower concerns of direct nerve/muscle stimulation (better than CN 7 and its muscles)?

That would be the tongue.

Here's the reality of it:

If you stick the traps, not a single person will question you.

If you start putting electrodes in the tongue on spine cases, you'll have to answer to the surgeon, anesthesiologist, nurses, etc.

Some may accept the reason. Others might not. Maybe some say to do it in myelopathic patients only.

Who knows until you start having those conversations.

Kim, D. G., Jo, S. R., Youn, M., Hyun, S. J., Kim, K. J., Jahng, T. A., ... & Park, K. S. (2017). Corticobulbar motor evoked potentials from tongue muscles used as a control in cervical spinal surgery. Clinical neurophysiology practice, 2, 124-129.

05/13/2026

The most common change in adult spinal correction surgery? Anesthesia? Positional? Legitimate guesses, but not it. Results below.

A new paper's results showed a different story.

Those are secondary issues of doing the surgery, but it was the actual maneuvers of the surgery that, by a large amount, were the cause of the most signal changes.

Sounds reasonable, but not always the collective experience when speaking to others in the field.

Or my own, which would have positioning and anesthesia much higher.

See the below results for adult spinal deformity cases and let me know if it matches your experience.

The most frequent causes of IONM changes were due to surgical maneuver (86.3%), followed by changes in blood pressure/temperature (11.4%), unknown cause (1%), patient positioning (.7%), oxygenation (.3%), and anesthesia (.3%).

Cottone, C., Kim, D., Lucasti, C., Scott, M. M., Graham, B. C., Aronoff, N., ... & Patel, D. (2024). Causes of Intraoperative Neuromonitoring Events in Adult Spine Deformity Surgery: A Systematic Review. Global Spine Journal, 21925682241242693.

05/11/2026

See you all there!

05/11/2026

Level 1 IONM understanding is this: 50/10 SSEP and all-or-none tcMEP alarm criteria. Place your markers and you're good...

But, like most things in life, any single measurement without context is weak.

Especially when you understand where the numbers came from and how math almost always lies.

That's right... math can and does lie. 🤯

𝗙𝗶𝗿𝘀𝘁 - These measurements were gained through empirical grounds, not some finely tuned measurement instrument with high precision and accuracy.

It's an observable range.

𝗦𝗲𝗰𝗼𝗻𝗱 - when you start looking at ranges, you might use a little math to tidy things up.

Maybe you eliminate some outliers and then take an average. Those outliers are important to consider when we're talking about surgery.

Even if you didn't, you still lose out on the truth.

An often-cited example is the "Bill Gates walks into a bar in anywhere USA" joke. All of a sudden, on average, the patrons of that bar are multimillionaires.

𝗧𝗵𝗶𝗿𝗱 - the numbers were probably manipulated for the sake of ease.

Say that average comes out to 47.8%. Well, 50% sounds much nicer. So let's go with that so we can better educate the masses.
___________

And this is where we might find ourselves in trouble. These pretty numbers can act as anchors and change the way we think about the problem.

I've had surgeons not sweat it at 45% solely because we didn't hit 50% yet. Another stimulated a screw over 5 times because no matter how he placed the probe on the screw I always got a CMAP of 7.2 mA.

Yes, he asked to go by tenths to clear the holy grail of 8 mA.

In these instances, we are thinking more like accountants -- looking at the cold, hard numbers -- when we should be thinking like auditors.

For auditors, context is key. There's more to this than a rounded, specific threshold, including:

1. response variability
2. anesthetic usage
3. the presence or absence of pre-existing neurologic injury
4. the rate of response change
5. surgical events at the time of change
6. end organ or generator points targeted

To do this well, it will take a couple of (very worthwhile) steps.

The surgical neurophysiologist and remote reader have to step up their knowledge base. They also need to establish/maintain great working communication with the surgical team, so that these points of context are understood before, during, and after the procedure.

In today's march towards value-based care, 50/10, all-or-none, and 8 mA aren't going to cut it.

And that's a good thing.

05/07/2026

Non-spine hasn't caught onto the adoption I would have guessed. Just looking at the hip, there are some go-to cases, and some still proving themselves out.

For hip joint surgery, IONM has been used for primary total hip arthroplasty, total hip arthroplasty revisions, periacetabular osteotomies (PAOs), hip arthroscopy, arthroscopic-assisted treatment of hamstring avulsion, and ischial tunnel syndrome.

A study looking at multimodality monitoring (SSEP, tcMEP, EMG) on surgical hip dislocation for femoroacetabular impingement found changes in almost 50% of cases.

Of those changes, there were 0 deficits.

So what gives?

Here's where it really helps when the surgical team understands what a change means and how to use it in the context of the surgery.

While there might be some cases of injury to the nerve through surgical approaches or maneuvers, it seems that sustained traction of the nerve is the primary cause of signal changes in these cases.

Many changes were not immediate (the paper does a good job talking about delays seen in SSEP vs tcMEP and why tcMEP might not be as useful due to the need for mm relaxations). This should help indicate a potential stretch injury.

So, what's in a stretch that causes changes?

• it could be due to injury to the nerve and/or nerve fibers
• it could be a localized blood flow issue to the nerve due to the orientation of the vessels into the nerve. We might call that a local low flow or no flow of blood supply
• it could be due to a stretch on a larger vessel, causing more gross changes in the blood supply

The first one is less likely to be time-dependent and you might assume a more abrupt change. If the positioning is steady, you'd assume it happens at the point of the dislocation maneuver.

The other 2 possible causes are time dependent. Meaning if you reduce the traction in time, there is no noticeable injury to the nerve.

These are our physiologic signal changes. Some will always be OK once the traction is released, and some are time-dependent.

And this is where IONM during hip surgeries is beneficial.

An intraoperative marker or pointer that would help modify patient positioning, retractor placement, or point toward swifter completion of the remaining part of the procedure is a valuable tool for safer surgery.

Hesper, Tobias & Scalone, Brian & Bittersohl, Bernd & Karlsson, Silja & Keenan, John & Hosalkar, Harish. (2017). Multimodal Neuromonitoring During Safe Surgical Dislocation of the Hip for Joint Preservation: Feasibility, Safety, and Intraoperative Observations. Journal of the American Academy of Orthopaedic Surgeons. Global Research & Reviews. 1. 10.5435/JAAOSGlobal-D-17-00038.

05/05/2026

Conflicting IONM signal changes lead to the rule "When you hear hoof beats, think horses, not zebras." And so we troubleshoot, but here's when to break it...

Well, not break it, but start considering zebras after we troubleshoot.

(Almost) without fail, if you're getting something screwy, something got screwed up.

Can't get a TOF?

Well, either some mm relaxants were slipped in, or you're recording or stimulating from the wrong areas.

We check our pods and smack our heads for mixing up our rights and lefts (or something else).

For the most part, we should be able to spot most screw-ups if we either don't see the response we expect, or it's inverted.

But when things check out, we increasingly consider differentials out of the ordinary.

Sometimes it's some anatomical variant outside of what we learned from Netter's textbooks. Other times, it's potentially an underlying condition.

___________

In the case study cited below, they had changes that weren't as straightforward as you'd assume in this C3-7 ACDF when troubleshooting checked out.

+ EMG in the bicep, loss of bilateral lower extremity SSEP, loss of hand/leg tcMEP responses...

All with an intact ulnar nerve SSEP.

So let's think through this...

- EMG in the Delt puts us upper/mid cervical (C4-7). Textbook calls it C5.
- we lost B LE SSEP after, so we know the dorsal column was affected. It's affecting the cord.
- we lost L hands (no BSL on R hands) and lower extremity, but not rostral muscle groups.

BUT, the ulnar nerve SSEP (C8-T1) was preserved. How could we spare that one tiny section of the spinal cord?

It's easy to get blinders on and think through possible effects due to the surgical injury, If you weren't able to get your mind out of the level of the cord, you might not have come to a potentially correct differential.

Martin-Gruber anastomosis explains it. (If you don't know what this is, Google it and look at the image).

We don't start with Martin-Gruber (it's rare), but we need to know when a horse is a zebra.

And have a good reason to add/remove it from our differential list.

Shore, S., Sabetta, Z., Schneider, L., Taylor, Z., Chyatte, D., & George, T. Martin-Gruber Anastomosis Explains Bizarre Intraoperative Neuromonitoring Data: A Case Report. World J Surg Surgical Res. 2024; 7, 1521.

05/04/2026

We’re actively hiring IONM Clinicians across multiple markets.

Current priority locations: NYC, DC Metro, Milwaukee, Houston, Denver, Tucson, and Southern California

If you’re open to hearing about new opportunities—or just curious what’s out there—send me a message.

Happy to share details on teams, cases, and growth paths.

Intraoperative Neuromonitoring

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