http://www.intraoperativeneuromonitoring.com/

Intraoperative Neuromonitoring, Orlando, FL (2026)

01/19/2026

Are you ready for a history lesson in ?

Francesco Sala came out with a paper that chronicles major milestones in pediatric IONM.

Usually, this is the place where progress took place.

From a neuromonitoring standpoint, pediatric cases tend to require more modalities more often.

Pediatric surgeons, at the same time, became more familiar and inquisitive about what's possible.

Much of IONM's progress took place here, necessity being the mother of invention and all.

Besides getting a better understanding of our history in the operating room, there are some additional points to take away from Sala's paper:

- appreciate the rate of adoption
- better understand the problem and thought process of creating a solution, and how that might map to other problems to solve
- the importance of being familiar with "seminal" papers. These tend to either stand the test of time or act as scaffolding to build on.
- make sense of the stories from those with decades in the field. There was a lot of new adoption in the 90's, and early 2000's... all at a time when information distribution was a fraction of today.
- helps better prepare you to understand what's coming next. He gives 2 examples at the end.

This one is open access, so go grab it and take in some history.

Sala, F. Intraoperative neurophysiology in pediatric neurosurgery: a historical perspective. Childs Nerv Syst (2023).

01/16/2026

Here's how companies with a great culture can have a toxic local culture by being mismanaged.

1. No 1:1 on the calendar - this is the employee's time. Ignoring this is silencing the staff.

2. No delegation - No chance to learn new skills and get better.

3. Minimal feedback - no clarity on what good and bad looks like.

4. Sugarcoating facts - sets you up for breaking management's #1 rule... no surprises.

5. Too many meetings - kills momentum. Prioritizes preparers over exectors.

6. Not building systems - Goals are ambition dependent on the systems in place. Don't start at step 2 until step 1 is in place.

7. Transactional relations - If there's no there, there, then there's no reason to stay here.

8. Not saying "no" enough - no one else will prioritize if you don't. Keep your yeses for your highest needs.

9. Ignoring risk management - this world is probabilistic. Don't just play to win, play not to blow up.

_______________

A bad local culture usually has 2 places a finger is pointed.

- a bad apple that is spoiling the bunch

- the local manager

Both could be part of the problem, but an organization needs to look at the tools given for the local team to be successful.

Many times, the bad apple was once a culture carrier. Something caused them to get/stay salty.

And

Many times, the local manager hasn't been taught how to manage/lead a team.

An organization should take a step back and see if these 9 items are a missing part of the manager's routine. The chances of having a case of the bad apple or evil manager tend to drop significantly when you do.

01/14/2026

There's one area of the nervous system that's been underserved by the neuromonitoring community: the cerebellum. Here's what's new...

I actually just had a text conversation with a D.ABNM about this exact thing. So I went looking for answers.

It's in the early stages of understanding, but every and clinician out there working in a pediatric center should be aware of what's progressing.

From the article:

"The inhibition exerted by conditioning stimuli at 8 ms on the motor cortex excitability is likely to be the product of activity along the cerebello-dento-thalamo-cortical (CDTC) pathway. We show that monitoring efferent cerebellar pathways to the motor cortex is feasible in intraoperative settings. This study has promising implications for pediatric posterior fossa surgery with the aim to preserve the cerebello-cortical pathways and thus prevent cerebellar mutism."

Here's how they did it:
- electrode strip on the cerebellum under the dura outside the craniotomic window
- bipolar stimulation from the electrode
- set the current intensity of 15–25 mA
- stimulate the cerebellar cortex at 500 Hz ranging from trains of 2-5
- stimulate transcrial MEP 8-24 ms after the cerebeller stimulation
- look for a clear inhibition with cerebellar stimulation of the MEP (8 ms seems to do the trick as the starting point)

Their prediction?

"Using this cerebello-cortical paradigm during surgery could be used to predict, and potentially prevent, CDCT disconnection in children operated on in the posterior fossa. This may help reduce postoperative cerebellar mutism and improve children’s quality of life."

With more study, we might have a new tool in posterior fossa surgery to help prevent injury.

Anyone out there already trying this out?

Giampiccolo, D., Basaldella, F., Badari, A. et al. Feasibility of cerebello-cortical stimulation for intraoperative neurophysiological monitoring of cerebellar mutism. Childs Nerv Syst 37, 1505–1514 (2021).

01/12/2026

The best neuromonitoring clinicians understand the surgery and IONM using these 4 steps: Problem - Solution - Result - Decision.

If you're lucky enough to get a good neuromonitoring trainer, they'll introduce you to aspects of the surgery you'll want to look out for.

For instance, when the surgeon asks for a rongeur, what does that mean during that specific case with the modalities you're running?

But before you even get to that point, start with a bigger picture and have a discussion where you take the perspective of the other members of the surgical team using the steps of Problem - Solution - Result - Decision.

The problem might be what you're there to solve (think the reason the surgeon invited you) or the problem you cause (think anesthesia's protocol).

The solution is what you can offer, knowing its strengths and weaknesses.

The result is the information you relay under the context it deserves.

And the decision is what action is taken or avoided, with your input (if needed) of probabilities.

If you're preparing for a case you have less experience with, you can read papers looking to pull out these same 4 steps.

For instance, here's a snippet from a peripheral nerve case where the surgeon is removing a tumor from a nerve.

"The ulnar nerve and its fascicles overlying the tumor were then stimulated with the assistance of the neuromonitoring team. An electrically “silent” zone on the posterior aspect of the tumor was then identified and opened sharply so that the true capsule of the tumor could be gently dissected.

This allowed us to preserve the fascicles of the ulnar nerve, which were functional. There were two small fascicles entering the tumor, which stimulated at higher current levels.

Because they clearly entered the tumor, they could not be preserved during tumor resection. There were three tiny fascicles exiting the tumor, which also had a higher threshold for stimulation.

Therefore, these fascicles were also divided in order to allow complete resection of the tumor en bloc. There was no motor response during sectioning."

Going through the literature with this purpose can help you better prepare by understanding what decisions will be made by the results of the solutions you offer to the problem looking to be solved.

Miranda, S. P., Nguyen, J., Gu, B. J., Ali, Z. S., & Zager, E. L. (2023). Allograft nerve repair to prevent sensorimotor loss after nerve sheath tumor resection. Neurosurgical Focus: Video, 8(1), V16.

01/09/2026

Here are two clinicians who end up working themselves out of a job in neuromonitoring...

The first is probably the easiest one to identify. They're "The Minimal Effort" clinicians.

They show up when the patient rolls in, don't talk to people in the OR to figure out what's needed, and respond to questions with incomplete responses.

The Minimal Effort clinician avoids effort to keep up or grow their skills. But they also aren't spending calories on effective communication.

It might be hard to tell if there is a communication problem, or just a coverup happening.

If the local team doesn't make enough waves to management (their job depends on the actions of others and one bad apple can spoil the bunch), the surgeon/facility will eventually ask they not return.

But that's the easy one. The other one catches people by surprise.

"The Authority" clinician.

It's the ones who put in the work... and can't help themselves and show it. They tend to have a lot of letters behind their names that help to prop up an ego.

They prioritize esteem over effectiveness.

During stressful times -- when a change happens -- is when it becomes clear as to a communication problem.

They end up citing the literature, maybe name-dropping authors or associations and drop in potential relative counterpoints to round things out.

The response ends up being circular as if they're trying to work things out in the moment. The gist ends up being inconclusive.

But when time matters, brevity reigns supreme.

Showing off your depth of knowledge, or using resources to preemptively prove you're right before someone questions you, creates a breakdown in clarity.

There's a time, place, and willing audience for that type of conversation. It's not when you lose the L tib motor response.

The manager typically gets a call from a surgeon saying they want someone who will "actually give me an answer."

________________

In a lot of areas, it doesn't take too many of those calls to work yourself out of the job. Those mistakes have been made by others and will be made again. Make sure it's just not by you.

01/07/2026

More so than ever, the cost of IONM is a big part of the discussion. Cost to facilities. Cost to patients. NASS came to some conclusions...

First off, there's one thing that stuck out to me in a reference they made to another paper. (Laratta, 2018) looked at who uses IONM:

- IOM was significantly more likely to be utilized at urban teaching hospitals (72.9%) rather than nonteaching hospitals (25.0%) or rural centers (2.2%).
- Private payors more so than gov payors.
- Per zip codes, there was a substantial difference in the rates of IOM use between low (19.9%) and high-income groups (78.1%).

Most likely due to accessibility and economics. However, the following findings are important for all surgical facilities to consider.

______________

There are plenty of proponents of increasing surgical safety, even if the numbers on a spreadsheet don't fit just right. This paper uses robotics in surgery as a comparison to IONM services, even though IONM is much cheaper.

But we should also be concerned with absolute cost, seeing the current financial shape of the US healthcare system.

Here's what the numbers showed:

For the people = from a societal perspective, the IOM strategy was dominant, suggesting that better outcomes were achieved at less cost.

For the facilities = from a health system perspective, IOM is cost-effective, yielding better utilities but at a higher cost than the non-IOM strategy

And how's this for a conclusion coming from NASS:

"Intraoperative neuromonitoring in spine surgery appears to be highly cost-effective in most real-world scenarios. This suggests the need for more widespread utilization and acceptance in this increasingly challenging healthcare climate."

_________________

This is an important paper for the field for practitioners, users, payors, and patients.

I'd suggest giving it a read and having it ready as part of your IONM discussions.

CONTROVERSIES IN SPINE CARE| VOLUME 14, 100206, JUNE 2023

01/05/2026

ENT surgeries make up a good chunk of the neuromonitoring research. Some of the results we should be made aware of include...

Patients with total thyroidectomies who had IONM:

- shows better completeness of thyroidectomy.

- a lower incidence of transient RLN palsy.

- shorter operating time.

So, it better meets the surgical objective, with less risk of injury, and a reduced cost coming from OR time.

Seems reasonable for surgeons to want it for their surgeries and for insurance companies to pay for the services.

Veetil PP, Puzhakkal S. A Comparison of Completeness and Complication of Total Thyroidectomy with or Without Neuromonitoring. Indian J Otolaryngol Head Neck Surg. 2023 Sep;75(3):1647-1650. doi: 10.1007/s12070-023-03686-5. Epub 2023 Mar 23. PMID: 37636658; PMCID: PMC10447815.

01/02/2026

Internally, we talk about the shift from unilateral tech to something different. Worlds are colliding and new roles will emerge. Here's planning out loud...

The scenario here isn't happening tomorrow and isn't guaranteed to play out, but it's something to be aware of so you're prepared for early opportunities.

If we look at our space of neurodiagnostics, there are different races to finding the next tool that will shape how we diagnose and manage some of our biggest health problems.

Solving for diseases commonly found in the aging population is primed to make the winners a nice return, plus allow for those looking for what's next in their career to have something to pivot towards.

Reading through this paper, Sub-Scalp Implantable Telemetric EEG (SITE) for the Management of Neurological and Behavioral Disorders beyond Epilepsy, it starts to make sense how we might find different subgroups coming to work in similar spaces.

If SITE works out in multiple neurological conditions, it might help unlock some other promising treatment options (deep brain stimulation comes to mind).

Could our DBS folks start interacting with our EEG folks? Or would that job now require a broader skillset that encompasses both?

Or could current world EEG techs find themselves as part of a treatment team, not just diagnostics?

Or would current world EEG techs be sought-after sales reps for products instead of just working as a service provider?

Of course, medicine and therapies will also be involved, and the lines will further blur when it comes to the current scope of practice. As well as where care happens (hint: in the homes).

There are, for sure, more obvious needs for moving away from unilateral work currently underway, but it's always useful to see what big problems others are working on. Those tend to change the way things are done.

12/31/2025

How to have an evidence-based discussion with a regarding IONM for a case...

The same approach can be used in other scenarios, like a deposition and/or oral boards for your company or the D.ABNM.

Step 1️⃣

A great first step is to grab a review of the literature from a reputable source. In this example, we'll be looking at:

CONGRESS OF NEUROLOGICAL SURGEONS SYSTEMATIC REVIEW AND EVIDENCE-BASED GUIDELINES FOR PATIENTS WITH CHIARI MALFORMATION: SURGICAL INTERVENTIONS.

This study isn't just about IONM, but the surgery itself. They are reviewing the body of evidence and giving a grade on the recommendations. One of the questions is this:

Is there a role for IONM in patients undergoing decompression for Chiari malformation type 1 (CIM)?

Their result?

Strength of recommendation: Grade C
All studies met the criteria for class III evidence. None met the criteria for class II or I evidence.

Step 2️⃣

Look at all the studies they reviewed to see how they came to their result + their conclusion of the studies as a whole. Go look those up and read through them to understand the details of each study individually.

Step 3️⃣

Look for trends. In the case of CIM, there are recent reports suggesting the use of dural patches without the risk. What does this mean for our section going forward?

Step 4️⃣

Think through questions left unanswered. This will help understand limitations and potential opportunities. For us, it might be which EPs are more sensitive to bony decompression, is the main utility in measuring conduction speed or preventing injury, can follow-up studies help predict long-term success.

______________

A review of the literature might get snubbed by the research community because it's not "real research."

But for me, it's always been a great tool to better understand strengths/weaknesses.

What other steps are you taking to better understand and communicate ?

12/29/2025

Do you know the effects of heat on the spinal cord as monitored by tcMEPs? Here's a helpful guide during radiofrequency ablation surgery...

There currently isn't a specific guide on what to expect at what temperatures. But a couple of studies can give us a clue.

The first is from a case report in the Journal of Vascular and Interventional Radiology.

They started to see R-sided MEP changes at 42 degrees C (see the image). The waves returned to BSL after cooling to 40 degrees C.

A second paper from Spine done back in 1992 had some more aggressive temperatures.

The spinal cords were heated by radiofrequency waves to a maximum of 47 degrees C momentarily or for 30 minutes.

"In maintained heating for 30 minutes, at 44 degrees C and below, the amplitudes decreased by one-quarter to three-quarters of the control value in the first 5 minutes and recovered to over three-quarters of the control value in 30 minutes.

The amplitudes returned to almost the control value after the restoration of normal spinal cord temperatures.

At 45 degrees C and above, however, the amplitudes were prominently reduced or disappeared in the first 5 minutes and remained depressed during the remainder of the heating.

The amplitudes did not return to the control value on normalizing the temperature. These results suggest that 44 degrees C in the epidural space is the highest tolerable temperature for normal spinal cord function."

So it seems we have a heat tolerable range of 42-44 degrees C when looking at tcMEP and cord function.

There are still some assumptions being made here, but those would be harder to put to rest outside of putting someone at risk.

12/26/2025

If you fly for work, you know the last couple of months have been a nightmare. Here's what travel can tell us about work and play.

You can miss your flight out of Orlando even if you're there 2 hours early. That is... if your flight even happens.

Even with all the stress of flying, the prices are still high. Looks like everyone's a jet setter again.

That could either be a good sign on how people view the direction of the economy or an ominous one that people need their breaks no matter what the cost.

Vacation is part of the modern era's poorly defined work-life balance. And as a healthcare provider, it's not like we can all just take off when we'd like to (for the most part).

So, how are you and your team working together to make it all work?

- Do you restrict the length of vacation at any one time?

- Do you have rules around holiday requests?

- What system do you have in place for emergencies that you all can handle locally?

How does your local team work to help each other with this part of

12/23/2025

Neuromonitoring has made its way to lung surgery, as the RLN (especially on the L) is at risk of injury.

But with the typical single lung ventilation, where should you place the electrode on the tube?

Here's what the authors concluded:

"Our results clearly demonstrated that the recording electrode should be affixed to the recommended left-sided DLT at least 10 mm, better yet 11 mm, above the proximal cuff."

Not a case I've been a part of, but interesting to see IONM finding new use cases.

Kirschbaum A, Jochens N, Stay D, Meyer C, Bartsch DK. Continuous intraoperative neuromonitoring of the recurrent laryngeal nerve during lung operations. J Thorac Dis 2023. doi: 10.21037/jtd-22-1515

Intraoperative Neuromonitoring

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