http://www.intraoperativeneuromonitoring.com/

Intraoperative Neuromonitoring, Orlando, FL (2026)

10/05/2026

The # of sweeps recommended for most evoked potentials is excessive.

The majority of cases would work just fine at 50-100.

Your time of acquisition gets much better. And time to determine changes is a major factor in preventing deficit.

Some of the recommendations for collecting 500-1000 sweeps might have been best practice for older equipment, but not something we should blindly carry forward.

If you haven't noticed already, some of the automated machines are selling speed. They tend to focus on the channels with a higher signal-to-noise ratio to help out (think cervical > cortical).

This, of course, comes at the expense of redundancy. But is that a worthwhile payoff?

10/01/2026

This is a paper every new talent hire should read and every veteran should review periodically. It will both keep you out of trouble (these are industry guidelines), better understand what best practices look like, and empower you to go off script in a pinch.

Toleikis, J.R., Pace, C., Jahangiri, F.R. et al. Intraoperative somatosensory evoked potential (SEP) monitoring: an updated position statement by the American Society of Neurophysiological Monitoring. J Clin Monit Comput (2024).

09/28/2026

Setup errors in now have a baseline error rate: 5.3%. That's ~ 43,000 cases a year. Here are some tips to minimize it...

First off, the authors have lent their advice. I only have access to the abstract now, so we might be reinventing the wheel here.

But off the top of my head, here are some variables likely to lower error rates:

- # of cases performed, up to a point (maybe after 1 yr/250 cases or so?)

- # of cases performed in a specific case type or modality used (10 cases or so?)

- familiarity with the program/platform used

- recency of specific case type or modality used (within the month?)

- training programs with a heavy focus on problem identification, troubleshooting, and resolution

- protocols that are consistent across different programs

- using larger protocols you can easily eliminate what you don't need vs many different variations of a protocol created for each specific scenario

- electrode color protocols that are consistent across different case types and modalities

- secondary protocols when a color is used more than once (like knots or tape at the end)

- battle-tested programs without the need for intraoperative tinkering

- program tinkering by inexperienced tinkerers reviewed by experienced clinicians every time

- sufficient prep time before the pt enters the OR

- sufficient setup time leading to baselines

- post-baseline checklist includes recheck of electrodes from pods to body (correct R vs L, correct anatomical location, etc.)

- troubleshooting help from an experienced clinician with OR experience, not just remote oversight experience

- quality audits with actionable corrections given, executed, and reviewed

- a culture of quality and patient care where high quality gets rewarded, and poor quality has consequences

What else do you suggest to lower setup errors?

Mandir, A., Ebinger, K., DeBruyn, L., & Kenney, K. (2024). A Prospective Look at the Prevalence of Setup Electrode-Swap Errors Across Over 450 Intraoperative Neuromonitoring Cases. The Neurodiagnostic Journal, 1–16.

07/09/2026

The #1 response to the question, "Are you doing LTM on your EEGs?" is...

"Yes. Well sometimes. And not all the way through the night."

Unless you are part of a monster unit, you probably don't have the staffing required to do it without killing your R.EEGs.

This, fortunately, is an easy fix.

Specialized groups with large, experienced remote teams can easily take on your studies without batting an eye.

Checking in within 2 hours, reaching out to the doc (as needed), and sending back a pruned report.

If this sounds like a potential solution to your problem, feel free to shoot me a DM and we can chat more.

07/08/2026

Larger groups or platforms have more advantage than just volume purchasing discounts on smaller/independant groups. It's access to anomalies.

Larger groups have more data, or more at bats. It's easier/faster to see what works and get to work on the change.

It's the 80/20 principle in action. And it works.

At the same time, it's important to not put on the 80/20 blinders. Not only is it easy for others to copy, or eventually come to that same conclusion, but it eventually loses upside.

It's a game of hitting single. Every once in a while, you need to swing for the fences.

While it makes all the sense in the world to track and implement best practices -- especially in our slow, continued creep towards value based care -- an ongoing and purposeful pursuit of anomalies have wothwhile upside.

Anomalies are found when you have the sensation of suprise, or oberve something important is missing.

Here's how to use suprise and identifying something missing as anaomalies arise:

#1 - Suprise

With best practices, the use of mathematics might mask your next big discovery.

If you're tracking anything, you might use excel formulas like averages. Or you might even remove any results two or more standard deviations out.

But taking the oposite approach, you might get a more visceral response... that of surprise.

Where excel scrubs out anything but the objective numbers, the person trained in openmindedness sits with the feeling of suprise and digs deeper.

They're willing to suspend their beliefs/understanding of how the world works and accept it might be broken.

- the midwifes who wash their hands before delivering a baby with lower mortaility rates.
- the surgical practice who uses hand written notes from the doctor and has the lowest patient abandonment scores.
- the operating room that used checklist before surgery with the lowest errors

These groups should encourage questioning norms and exploring new areas or counterintuitive positions by shinning a becon of light when something results in suprise.

Sometimes tracking what's suprising in what you have and asking "why" is better than persuit of the next best thing.

#2 - Handicaps

If all else equal, or close enough, what's working despite known deficits.

- A patient without access to more expensive care plans that improves all the same.
- A team leader with high net promoter scores who lacks any hint of charisma.
- A salesperson with great numbers who doesn't dial for dollars.

Who's doing the same or better with less? Is that scalable, or a new direction to head in?

Constraints, either purposeful or not, are good for innovation. There's a lot to gain by searching out current successes despite constraints, as well as testing your team's creativity by placing constraints and working your way out of the problem.

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.

Intraoperative Neuromonitoring

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