http://www.intraoperativeneuromonitoring.com/

Intraoperative Neuromonitoring, Orlando, FL (2026)

03/19/2026

Neuromonitoring made national news (again), this time for accusations of fraudulent billing and racketeering (RICO).

STAT/The Boston Globe published a 19-page investigative report (it's juicy). I have no firsthand knowledge of the validity of any/all allegations, so I don't care to go there. Google or ChatGPT will get you up to speed faster than I can.

The less headline-grabbing takeaway is the one worth sitting with: how each of us thinks about compliance and risk.

As in a hospital, a surgeon, a direct employee, or someone in the IONM field.

If you're a hospital administrator contracting with an IONM group, the question isn't whether your vendor is the one in the article. It's whether you know how they bill and if their structure is aligned for compliance or revenue extraction.

Do they balance bill? Do they keep billing in-house or outsource it on contingency? Do you know the org structure behind the group delivering and billing for care? Have you ever asked or requested attestations? Most haven't.

The NSA was built to protect patients from balance billing, but it shifted the risk, and that risk just got a lot more visible.

If you're a surgeon, the chances of being presented with a financial arrangement tied to neuromonitoring utilization aren't zero.

The 2023 OIG statement made the legal gray area real. And where lawsuits once targeted the monitoring company, the Texas Medical Board recently went after the surgeon. The risk shifted as the landscape changed.

If you're an IONM physician or clinician, the company you work for shapes your professional reputation whether you want it to or not.

You're the face in the OR, building trust with surgical staff, and when a patient gets balance billed or questions why neuromonitoring costs more than the surgeon, that lands on you, even when it's out of your control. That's lost business and contracts, regardless of the quality of care you deliver.

Knowing how your organization functions beyond the OR matters.

And if you're in the field working for a group choosing compliance as their billing model, you're not off the hook. The burden of proof falls at your feet due to proximity. There's as much risk in keeping quiet as there is in speaking up. Do or don't, just understand your choice.

____

The IONM field has spent years building clinical legitimacy. Cases like this don't destroy it. But they do put pressure on everyone to know who they're working with and what they're attached to.

The question worth sitting with isn't "is the company doing any of this?" It's "do I actually know enough to answer that with confidence, and what does it mean for me?"

If the answer is no, that's where to start.

02/02/2026

I'm hiring 2 Director-level positions for IONM business development. Details are below:

This Regional Director of Business Development (RDBD) sells SpecialtyCare's neuromonitoring services to surgeon offices.

You can be someone with clinical experience and evidence of growing case volume through surgeon selling, or someone with sales experience in healthcare, preferably to surgeons/physicians. US citizens only (sorry).

You report to me (VP of Market Development) and work alongside the area's VP of Client Services, Region President, Area Clinical Managers, Clinical Managers, and our Marketing team. You'll be part of our team selling philosophy, where we share goals and targets to hit. No sink or swim. No selling on an island.

The 2 regions I'm hiring for are outlined in the image. The RDBDs can live in one of our major market targets (West = Blue pins, Central = Red pins). Other major cities within the outlined geography can work as well.

It's a large area, but we will have ongoing planning to find the best use of your time. You can plan out your weeks/travel so you can have a personal life at the same time. Travel is estimated at 60% of the time.

Generous salary you can 2X with different buckets of commission/incentives. Easily obtainable for someone who takes initiative, works well with their team, and understands what it means to provide fantastic service to our customers.

If you're interested, please do the following:

- message me any questions you need up front
- if you're ready to go, send me your resume.

01/30/2026

Every time a company triples in size, what gets you to the next triple changes.

When you go from solo to three, to ten, to 30, to (maybe) 100 employees, there's still enough social connections to enable the company to function as a single unit.

The next tripling changes things drastically (this is where I'm at today).

The reason for this new challenge is due to the capacity of a human's operating system, or lack thereof.

We are good at keeping ties with others in our social groups up until the point around 150 people.

This is Dunbar's number.

At this point, teams (and culture) lean further towards local over general.

And that's ok, but not for everything.

A perfectly reasonable response from the organization is to increase the processes and policies.

"This is how we do expenses."

"These are the rules for requesting PTO."

"This is how we apply head leads."

By doing so, you can take the collective learnings from a large group of people and establish best practices.

Best practices help everyone know "what good looks like." And the results are almost always better than a free-for-all.

But it does have its drawbacks.

Innovation slows, and appreciation for context and nuance during each unique situation suffers.

And when taking care of patients, nuance matters.

It matters for each patient you're serving today.

It matters for preparing you to recognize when it's needed for your patient tomorrow.

Writing policies and procedures is hard because you'll never please everyone. But as long as it is coming from a best practice, that helps soften the landing.

Finding the cracks in the best practices and empowering employees to recognize and act accordingly is much harder, especially with Dunbar's number in play.

It's harder to assess the risk/reward across large groups of people. It's harder to give the tools needed to accomplish it too.

But it's worth it, because our customers are patients.

And this is where I'm at today. And with the likely consolidation in IONM and EEG companies, it's where a lot of you will find yourself.

So, who's got some pointers to share?

01/28/2026

Intraoperative surgical question: "Did the signals get better?" But is that the right time to ask it?

From my experience, the signal improvement doesn't happen once the nerve/cord is decompressed.

Exceptions might be in acute trauma. Or Chiari malformation.

But if we could look at pre-operative, pre-sedation SSEP signals and then compare those to postoperative SSEP signals, would that change the value of that question?

First, let's see some of the value that could come of it:

- could we grade certain surgical techniques against each other?
- could we grade what the patient's recovery might look like?
- could this help with establishing presurgical baseline integrity of the area being worked on, for medical legal purposes?

But there have to be some variables to consider, right?

Here are a couple, but would like to hear from you as well:

- the temperature needs to be consistent from study to study
- the electrodes should be measured out to keep distances equal
- what are the established time criteria to look for improvement (depending on the scope of the nerve injury associated with diagnostic EMG)
- what other environmental factors should be considered: pt health, age, type, and compliance with rest/rehab, etc.

Read the paper and then let me know your thoughts on the value of this technique and/or other questions to be answered.

Yeung, A. T. Porter (2018) SEP as A Sensory Pathway Integrity Check in Patients Undergoing Lumbar Endoscopic Spine Surgery Using the Yeung Endoscopic Spine System. J Spine S, 19, 2.

01/26/2026

Urinary, f***l, or sexual disorders in robotic re**al surgery can occur with surgical injury of the pelvic nerves. Monitoring with tissue impedance measurements is a novel technology in the space.

It's monitoring the autonomic nerves through stimulation.

First off, where might this be beneficial? From the paper cited below:

"Pelvic neuromonitoring can be performed with known standard neuromonitoring methods such as transcranial motor evoked potentials (tcMEP) from the external urethral sphincter (EUS) and external a**l sphincter (EAS), free-running and triggered EMG from the EUS and EAS, as well as bulbocavernosus reflex (BCR) measurement and pudendal somatosensory evoked potentials (SSEPs). All of these methods monitor afferent and efferent fibers of the pudendal nerve that innervate the motor sphincter muscles in the pelvic floor, which is mandatory in sacral spinal procedures. Functional control and identification of pelvic autonomic nerves are not covered, which is essential during low anterior resections."

Needles were placed intraoperatively into the bladder and re**um. The paper notes some unexpected difficulties in solutions when dealing with space-occupying lesions and proper needle placement.

Catheter electrodes in the urethral sphincter and re**al probe in the a**l ca**l were used to compare the impedance of the tissue layer between these electrodes and the needles placed.

Continuous monitoring + intermittent mapping for selective localization of the hypogastric plexus was used.

Interpretation of a positive response:

(a)
new onset of change in the impedance signal after application of direct nerve stimulation

(b)
similarity of the signal waveform and morphology with the impedance signals derived in the animal study

(c)
duration of the impedance change of several seconds, correlating with the duration of a slow smooth muscle contraction after evocation of spikes (3–15/min)1

(d)
confirmation of the positive signal response by a negative control in the surrounding tissue, where no nerves are expected

A negative signal response was considered as no change in the impedance signal after the application of direct stimulation to a control tissue portion.

Results

Seems they had a consistent ability to stimulate and record with noted preservation or minimizing surgical effects.

As noted in the paper, more time to assess the outcomes and a larger sample size would help determine true outcome differences.

___________

Overall, a good paper to read to:

1) Stay up to date on what's coming around the corner
2) Beef up on your understanding of filter settings and potential difficulties that can arise during surgery

Schuler, R., Marquardt, C., Kalev, G., Langer, A., Konschake, M., Schiedeck, T., ... & Goos, M. (2023). Technical aspects of a new approach to intraoperative pelvic neuromonitoring during robotic re**al surgery. Scientific Reports, 13(1), 17156.

01/23/2026

Using EEG for TBI has been limited to rule out potential nonconvulsive status epilepticus. But there's a new reason: secondary brain injury.

TBI uses the IMPACT score as the best available predictor of future injury, based on clinical, radiological, and laboratory findings.

As good as it is, it doesn't tell the whole story.

A recent paper hints at the importance of EEG features compared to IMPACT parameters alone. The combined EEG and IMPACT model revealed that, apart from age, the most contributing features to predict poor outcomes were EEG features (see the image).

Why is this important?

EEG features are the potential sensitivity to secondary injury. Secondary injury is believed to be at least equally important in explaining neurological outcomes compared to primary injury.

IMPACT parameters are a reflection of primary injury.

So, a combination of measures sensitive to primary (IMPACT) and secondary (EEG) injury may lead to better prediction of outcome.

But there's more to it.

EEG has a sensitivity to tracking synaptic damage. And there's preclinical, and animal work suggests that secondary damage is significantly reflected in synaptic damage.

hashtag has started to make its way to assessing TBI patients, and more neurologists, non-neurologist physicians, and healthcare providers are using the information gained to better treat over the entire patient journey.

Tewarie, P. K., Beernink, T. M., Eertman-Meyer, C. J., Cornet, A. D., Beishuizen, A., van Putten, M. J., & Tjepkema-Cloostermans, M. C. (2023). Early EEG monitoring predicts clinical outcome in patients with moderate to severe traumatic brain injury. NeuroImage: Clinical, 37, 103350.

01/21/2026

Are you ready for a history lesson in ?

For many neurologists, the ability to observe the sequence of events within a seizure episode is just as crucial as capturing abnormal brain waves through electroencephalography.

But in-person, real-time observation doesn't scale to the needs of our patients, the availability of providers, and the reimbursement model.

So we innovate.

And what did innovation look like on a 100+ year timeline?

Photography and art.

And then cinematography.

And then computers and videocassette recorders.

And then modern digital cameras and cloud computing.

Besides being an interesting read on the progress of EEG from a delivery and utilization standpoint, there are some other key points to take away from the (Ho, 2023) paper.

- Amazing the contributions of some within the field. You might recognize some of the names (Charcot - the same doctor who described the brain’s vascular supply, differentiating tremors found in Parkinson’s disease with those of patients with multiple sclerosis, differentiating hysteria from epilepsy, being one of the first physicians to set up rehabilitation clinics for the treatment of his patients, and formulating a triad (known as the Biliary Triad) for diagnosing acute cholangitis which consists of right upper quadrant pain, jaundice and fever) oftentimes combines formal training with some other skillset they bring to the field, just like Steve Jobs and calligraphy did for Apple.

- Progress in other distant areas can have profound effects on healthcare. Just like the Apple phone did for transportation, music/video, communication, leisure, and business, the adoption of outside innovation will create healthcare delivery options previously impossible.

- help understand the next generation of EEG is prolonged studies, wearables, and/or implantables, and mobile. Neurology is unbundling.

Ho, R., & Carrazana, E. J. (2023). The History of Motion Photography to Video Electroencephalography in the Study of Functional Seizures and Related Seizure Disorders: The First 100 Years. Seizure: European Journal of Epilepsy.

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.

Intraoperative Neuromonitoring

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