Real Time Neuromonitoring Associates - RTNA

Home
United States
Nashville, TN
Real Time Neuromonitoring Associates - RTNA

Real Time Neuromonitoring Associates (RTNA) is the country’s leading professional oversight practi

05/25/2026

This , we honor those who made the ultimate sacrifice in service to our country.

05/21/2026

Looking for some literature that speaks to the importance of supramaximal stimulation? Check out these references:
•https://asnm.org/wp-content/uploads/2024/08/Toleikis-2024-Intraoperative-SSEP-monitoring-An-updated-position-statement-from-the-ASNM.pdf
• https://link.springer.com/article/10.1007/s10877-022-00972-5?utm
• https://pubmed.ncbi.nlm.nih.gov/17635389/

05/14/2026

What Does Supramaximal Stimulation Look Like in TOF?
When obtaining TOF responses, the goal is supramaximal stimulation. As stimulus intensity increases, CMAP responses become larger and more distinct. Once the twitches reach their maximal size and stop increasing, supramaximal stimulation has been achieved, and the IONM Team can be confident that all available nerve fibers are being activated.

In this example, the TOF stimulus is titrated, with increasing intensity producing corresponding increases in amplitude until they begin to plateau around 55 mA, the supramaximal threshold. Although this is already supramaximal, it is good practice to go slightly above the threshold - typically 10–20% higher. Responses were obtained up to 85 mA, but such a high stimulus was unnecessary, illustrating that higher intensity does not always produce larger amplitudes. Therefore, the technologist appropriately set the supramaximal TOF baseline for this patient at 60 mA.

05/07/2026

What Does Supramaximal Stimulation Look Like in SSEPs?

When capturing SSEPs, think cause and effect. As stimulus intensity increases in the submaximal range, cortical and subcortical amplitudes should increase as well.

At the point when all the nerve fibers that can contribute to the response are activated, increasing the stimulus no longer improves amplitude or waveform quality. The response plateaus—this indicates supramaximal stimulation.

If the technologist has set a stimulation level 10–30% above the supramaximal threshold, they can remain at this level, increase, or slightly reduce the stimulus with confidence the response is still supramaximal for that patient.

Example: In this case, cortical waveforms increased with stimulus titration, and the response plateaued around 35–40 mA, suggesting the supramaximal stimulus for this patient.

04/30/2026

What is Supramaximal Stimulation?
Supramaximal stimulation means applying a stimulus just above the supramaximal threshold - the point at which all nerve fibers contributing to the response are recruited*. This is often confirmed by a visible muscle twitch. It is not simply turning the stimulator to its highest setting. Typically, it’s best to stay about 10–30% above this plateau intensity, since excessive stimulation can sometimes activate nearby, non-target nerves.

When is it important?
Supramaximal stimulation is particularly relevant for SSEPs and TOF testing. Some would argue that it is also helpful for MEPs in spine cases, though it’s less applicable for MEPs in craniotomy procedures, where higher stimulation may risk activating deeper subcortical structures.

Why it matters in :
✅ Stronger and more reliable signals – Maximizes amplitude and stability, creating greater resiliency against electrical noise or anesthetic effects.
✅ More reproducible – Because the supramaximal range is based on a physiologic response, it can be consistently reestablished. Device settings alone cannot guarantee reproducibility if electrode contact changes.

In short, supramaximal stimulation helps produce strong, stable, and reproducible data, which is essential for meaningful monitoring.

In this image the Supramaximal Zone is highlighted in blue, indicating the point in which all nerve fibers contributing to the response are recruited. It’s within this zone you want to set stimulus intensity.

* Not all nerve fibers are recruited at this threshold. Smaller pain fibers may remain inactive.

04/20/2026

Join us in celebrating our neurodiagnostic community during 🎉

04/14/2026

We’re officially accredited by Joint Commission! This recognition reflects our commitment to upholding the highest standards of quality and safety in patient care. Learn more: https://rtnassociates.com/about-us/

03/31/2026

Fix CMAP clipping by increasing the amplifier gain of recording muscle. In this image you will see baseline clipping in the TOF (blue trace). This is resolved with increase of amplifier gain.

Want to double-check your technical setup and make sure clipping is avoided? Check out the parameter setup RTNA recommends for TOF.

03/25/2026

What’s the big deal with waveform clipping?

Accurate waveforms = reliable waveforms.
Reliable waveforms = IONM team can trust the data.
Trusted data = Surgeons get high-quality information.

And most importantly… our patients get the high-quality care they deserve. Here’s a case example. During a thoracic spine correction, baseline MEPs include hands that are clipped while the feet are not. How could this create problems later?

Imagine the foot responses attenuate as the case progresses. You and your supervising clinician now need to decide: is this a global change or something isolated to the lower extremities?

If the hand baselines were clipped from the start, you lose a clean comparison point. Without an accurate upper extremity reference, it becomes much harder to determine whether the attenuation is systemic or focal. Signals may appear present but aren’t fully interpretable, and that uncertainty can impact real-time clinical decision making.

All of this can often be avoided with a quick adjustment to the amplifier gain for the clipped channel at baseline.

03/18/2026

Huge news! 🎉 We’re pleased to announce that RTNA has achieved accreditation from Joint Commission!

The Joint Commission’s accreditation process validates our dedication to top-tier quality and safety standards, highlighting our culture of continuous improvement and commitment to excellent patient care.

Huge shout out to our incredible team who helped make this possible! 👏

03/17/2026

🎉 Exciting news! 🎉 We’re pleased to announce that George “Trey” Lee, III, MD, founder of both Real Time Neuromonitoring Associates and Real Time Tele-Epilepsy Consultants, is the President-Elect of the Tennessee Medical Association (TMA).

Dr. Lee will serve one year as President-Elect, one year as President, and one year as Immediate Past President. His primary role is to serve as the face of the organization and spokesman for TMA with its membership, the media, government officials, and the citizens of Tennessee. Read More: https://members.tnmed.org/news/Details/dr-george-r-trey-lee-iii-voted-tma-president-elect-new-board-and-judicial-council-members-elected-315910

Please help us congratulate Dr. Lee on this well-deserved achievement in the comments below 👇

Address

Nashville, TN
37203

Telephone

+16153468182

Website

http://rtnassociates.com/

Alerts

Be the first to know and let us send you an email when Real Time Neuromonitoring Associates - RTNA posts news and promotions. Your email address will not be used for any other purpose, and you can unsubscribe at any time.

Shortcuts

Want your practice to be the top-listed Clinic in Nashville?