http://www.intraoperativeneuromonitoring.com/

Intraoperative Neuromonitoring, Orlando, FL (2025)

11/20/2025

EEG to help with the identification of at-risk and more specific treatment plans for those with su***de ideation and su***de attempts?

There still seems to be a discrepancy on what a reliable marker might be, slowing in the frontal lobe, duration needed, right vs. left side, etc.

Is there anyone out there currently using EEGs in this capacity? The discussion around it doesn't seem to be in line with the size of the problem (700,000 su***des each year).

What protocols or algorithms are being used?

11/18/2025

I asked this question 2 years ago. My guess: it's probably the same today, but won't be in another 2 years.

Every day, I'm having a conversation with ChatGPT. And so are my kids.

The amount of fluff in books and wasted time scrolling on social media looking for nuggets is easily the first thing I'm ready to drop. Add in fake accounts, audio, video, etc., and swimming in those waters becomes dangerous. Having back-and-forth conversations with AI won't just be a better way to learn; it might be the only one we can trust.

And that's crazy to consider.

11/15/2025

Ambulatory LTM EEGs = Big files. Really, really big.

While some are still using FedEx and anything short of pigeon carrier, most everyone is looking forward to the day when uploading to the cloud at least broaches the border of reasonable.

Improvements in readily available lossless compression can help us get part of the way there.

As there continues to be a shift to moving LTM EEGs to the patient's homes, plus the development of wearable EEGs, solutions like this help with a current bottleneck.

Making these files more "sharable" will take EEGs a long way.

Sometimes it's not about finding the new thing. It's about reducing the friction of what's currently available.

11/14/2025

Place your bets... will routine EEG rival ambulatory EEG's sensitivity measures for a first single unprovoked seizure?

If you look at the historical practice, you'd have to believe it's got to be close, right?

For so long, we were programmed to do a routine before ordering a long term.

Even now that that restriction has been lifted, that pattern has been slow to break.

But does 20-30 minutes of EEG meet an acceptable sensitivity, or a test's ability to designate an individual with disease as positive?

Or would the results be so much worse that you'd be better off collecting longer studies and capturing full sleep?

That's what this study looked to answer. Here're the results:

Ambulatory EEG captured IED/seizures with a sensitivity of 72%, compared with 11% for the first rEEG and 22% for the second rEEG.

More data points would be needed, but the difference is a bit surprising, no?

Of course, you need to define your goal for the EEG, but the evidence is building for studies 3-7 days in duration to give the best chance to capture and properly categorize.

Diagnostic Accuracy of Ambulatory EEG vs Routine EEG in Patients With First Single Unprovoked Seizure
Lizbeth Hernandez-Ronquillo, Lilian Thorpe, Cindy Feng, Gary Hunter, Dianne Dash, Tabrez Hussein, Chelsea Dolinsky, Karen Waterhouse, Pragma Laboni Roy, Nathalie Jette
Neurol Clin Pract Jun 2023, 13 (3) e200160; DOI: 10.1212/CPJ.0000000000200160

11/04/2025

I'm for neuromonitoring in cities across the US. Experienced and not experienced positions open. Full time clinicians, manager, travelers, and contractor roles.

Open neuromonitoring positions

Birmingham, AL

Dothan, AL

Tucson, AZ

Bakersfield, CA

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Jacksonville, FL - CONTRACTOR

Miami, FL

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Rapid City, SD - CONTRACTOR

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Roanoke, VA - CONTRACTOR

Seattle, WA

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Milwaukee, WI

Milwaukee, WI - Clinical Manager

10/31/2025

Over time, the decisions you make reinforce how you'll make decisions in the future.

Going slow and prioritizing safety reinforces survival first.

The analogy is how the turtle used it's energy to evolve with a shell.

Current decisions are forced under the heavy weight of the shell, but also the reliance of it's protection.

The same could be said for animals the evolve to blend into their surroundings. The strategy is to sit idle (safely) and let the world play out around you.

Those prone to take on risk to learn faster evolve some other characteristics, like speed or intelligence.

For instance, fleshy octopus have evolved distributed intelligence.

They spent little energy forming armor and most of it on being better predictors.

Their survival came from a significant reduction in latency of action, greatly improved situational awareness, more accurate analysis, and advanced event detection.

Both strategies, obviously, can work.

Finding success probably has more to do with understanding what the current environment favors and how well you execute than one being better than the other as a rule.

10/29/2025

A recent Journal of Hand Surgery paper reviewed peripheral nerve IONM modalities. Why is this important to note?

Not because it came to any new breakthrough. It was a review article after all.

But because it's a notable journal being seen by an underserved audience.

Many of the historical publications were in journals geared toward and .

There's less press on neuromonitoring using nerve action potentials in .

It pulls its weight by being a primer, like outlining the main uses of IONM of the peripheral nerves and brachial plexus:

1. Identifying the peripheral nerves.
2. Locating preexisting lesions throughout the pathway of the nerve.
3. Determining continuity across a nerve lesion.
4. Determining whether there is root avulsion.
5. Identifying the targets for nerve biopsy.
6. Monitoring and preventing damage to healthy nerves during the intervention.
7. Obtaining an evolutionary prognosis of the neurological lesion.

It's a paper like this that gets surgeons curious to explore what's available to provide safer surgical options to their patients.

Nicole A. Zelenski, Tatsuya Oishi, Alexander Y. Shin, Intraoperative Neuromonitoring for Peripheral Nerve Surgery, The Journal of Hand Surgery,
Volume 48, Issue 4, 2023, Pages 396-401, ISSN 0363-5023

M. Herrera-Pérez, A. Oller-Boix, P.J. Pérez-Lorensu, J. de Bergua-Domingo, S. Gonzalez-Casamayor, F. Márquez-Marfil, L. Díaz-Flores, J.L. Pais-Brito,
Intraoperative neurophysiological monitoring in peripheral nerve surgery: Technical description and experience in a center, Revista Española de Cirugía Ortopédica y Traumatología (English Edition), Volume 59, Issue 4, 2015, Pages 266-274, ISSN 1988-8856

10/27/2025

30% of seizure diagnoses can't be made on the first seizure captured by . Here's why that's important...

The "time to first event" is often the most sighted measurement and is used as a proxy for sufficient monitoring time.

It's mentioned as part of the problem with the current point-of-care devices since most will miss seizure activity in that short window.

And if you ask an EEG tech and/or neurologist what the average length of their LTM study is, you'll almost always hear 72 hours.

But let's look at the different use cases for EEG and decide if a blanket response of 72 hours meets the same demands of the goal of the study:

- differential diagnosis between epileptic and non-epileptic seizures

- classification of seizures

- the assessment of treatment

This study highlighted that the difference in ave monitoring time needed between certain clinical indications is significant.

Diagnostic indications (whether a habitual event is an epileptic seizure or not) require a longer time than non-diagnostic indications (characterization and treatment assessment).

They concluded that unless you're assessing for changes in antiseizure meds, the ambulatory video EEG could lead to a missed diagnosis or inadequate epilepsy classification if the study is capped at 72 hours.

What was their recommendation if that's the goal of your EEG?

7 days.

And it's probably better to do it at the patient's home.

Skin breakdown and disruption of the patient's life are genuine concerns, but the high percentage of missed diagnoses is pretty compelling.

Victoria Wong, Timothy Hannon, Kiran M. Fernandes, Dean R. Freestone, Mark J. Cook, Ewan S. Nurse, Ambulatory Video EEG extended to 10 days: A retrospective review of a large database of ictal events, Clinical Neurophysiology, 2023, ISSN 1388-2457

10/24/2025

Here's an acid test for your direct or indirect managers...

At some point (it should actually be a recurring discussion), you'll have career discussions.

Test #1 is the more obvious.

Do they talk about you only in the role you currently hold, or do they discuss and take action on the role you may someday want?

It's easier to spot because it isn't about you, it's about them. It's a reflection of what they need out of you.

Test #2 is harder to pick up on because it's about how they truly see you. None of us can read others' minds, though we all try like hell and convince ourselves we can.

It's how they judge you based on where you are currently and not what you eventually become.

If your manager:

- embraces the short-term hiccups because they can see the long-term upside
- give you critical feedback even in situations where you "won" because it is aimed at getting to that better, future version of you
- evaluates today's activities and behaviors as a part of a larger equation

Then you have found a manager that you'll most likely refer back to when you think about people who had the most impact on you at work.

And that's important at any step of your career.

10/22/2025

To get better MEPs, sometimes you have to prime the pump.

Double train MEPs do this.

Even the manual "double-tap" seems to work well.

One other way to ramp the system is to stimulate a peripheral nerve prior to running your MEP.

Tetanic stimulation seems to work better. This is when you stimulate at a really fast rate (usually 50 hertz or greater),

The advantage of tetanic stimulation is thought to result primarily from the buildup of calcium concentration in the axon terminal of the presynaptic neuron during the stimulus train.

But there are postsynaptic effects too.

This is considered the case due to the change in decay pattern in the threshold distribution among the postsynaptic pool of potentiated motoneurons.

There is a larger decay up front, but it can last up to five minutes.

To take advantage of these effects, the authors looked to stimulate 1 second after tetanic stimulation.

__________

But why the pudendal nerve? What did they know that I didn't?

(From a different paper)

"In one infant at our institution, since conventional MEP was difficult to elicit, tetanic stimulation of the median and tibial nerves was supposed to be applied for enhancing MEPs. However, the technician failed to switch the position of the electrodes from the pudendal nerve for bulbocavernosus reflex (BCR) monitoring to the median and tibial nerves. When unexpected MEP augmentation was obtained as a result, the technician noticed that tetanic stimulation had been inadvertently applied to the pudendal nerve. Tetanic stimulation of the pudendal nerve was also found to lead to reproducible MEP augmentation in other cases involving BCR monitoring."

Happy accident.

10/20/2025

Incentives dictate behaviors, so you're bound to get what you optimize for.

Create only individual goals, you're tilted towards mercenaries.

Create only offensive goals, no one will be there to protect what's already yours.

Create only goals for the parts without considering the whole, the misalignment creates turbulence.

To do better is actually to go against the grain.

Humans, while the great cooperators, created strong social norms to prioritize competition over cooperation.

And it's always been a source of conflict.

It's not a bad thing, but it can't be the only thing.

As we moved out of the grow at all cost phase, rethinking incentives encouraging cooperation becomes an edge.

10/17/2025

Get the momentum, or eat the elephant.

Both pieces of advice are given as if it's gospel.

Start small and get some wins or do the big thing first, while you're fully charged.

Others -- like me -- take a different approach.

I start off with what takes the most mental concentration or creativity first, then on to the big thing.

But not always.

On all honesty, it's not the size or time commitment that matters.

It's the impact.

If you use something like the 1-3-5 method, make sure you rank it by priority.

"Are you fighting for inches, or yards."

Intraoperative Neuromonitoring

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