http://www.intraoperativeneuromonitoring.com/

Intraoperative Neuromonitoring, Orlando, FL (2025)

12/19/2025

We hear about long wait times for inpatient LTM, but most patients diagnosed with drug-resistant epilepsy never get LTM. That's ~1 mil people.

So, how underutilized is underutilized?

This study found only about 19%, though other reports are as low as 2.2% in Canada and 3.9% in California.

Yet, referrals to an epilepsy center for evaluation have been proposed since the 2003 AAN practice parameter and were reiterated in the current 2017 AAN Epilepsy Quality Measurement set.

Why is this a consistent recommendation?

Because epilepsy surgery with resection offers a 30%– 70% cure rate, compared to a

12/17/2025

Since Jan 2023, the most important abbreviation in IONM hasn't been SSEP or MEP or EMG. It's been AR.

AR is the Accounts Receivable, or the amount of money you expect to turn into revenue at some point.

And that's the problem. The rules of collecting AR has changed and it is causing problems for service providers.

There have been far more denials, appeals, and denials of appeals than what was anticipated (who could have guessed, right?) and everything is backed up.

And that bottleneck is a serious business and patient problem.

First, let's talk business.

We've already seen some in-market problems with Peak. There are also other health providers affected by the No Surprise Act, like Envision Health's bankruptcy (emergency medicine).

Any company that:

a) hasn't got enough money to float a dry spell

b) has taken on debt and has some immediate/ongoing cash needs

c) can't adjust fast enough to work in the new billing system

are bound to be in trouble.

Where VC money used to make all the sense in the world when money was cheap and reimbursement was higher, it can be the thing that kills off a lot of companies with headwinds.

Next, let's talk about patients.

The estimates for IONM use in the US and internationally are pretty aggressive. Like doubled by 2030.

The aging population just finds itself in the surgeries we monitor.

IONM has seen some turnover in the field, just like all health care. Trying to replace with new workers at a higher tick and downward pressure on reimbursement is going to be a challenge.

Even if we see consolidation in fragmented markets (smaller companies are more prone to get hurt by these insurance changes), that's still going to be a heavy lift.

Quality of care is bound to feel those effects.

And so it's the abbreviations AR we need to focus on, at least for the time being.

12/15/2025

Most in neuromonitoring are familiar with monitoring hashtag cases for chronic pain. But what about the more extreme Corodotomies?

Spinal cord ablation is almost exclusively used for refractory cancer pain and in the palliative care setting, whereas neuromodulation remains a more robust long-term treatment for patients with refractory chronic pain.

- Different patient populations.

- Different surgical goals.

- Different monitoring techniques.

Instead of utilizing the pain gate theory for pain relief, the surgical plan here is to target the spinothalamic tract.

At a given spinal level in the spinothalamic tract, axons come from cells located in the contralateral cord 2 to 3 spinal segments lower because the Lissauer tract conducts pain fibers rostrally and ipsilaterally before they crossover to join the spinothalamic tract.

So, pain control with cordotomy is achieved 3 or 4 levels below the level of the lesion.

With this surgery, we're looking to help preserve movement and light touch/temperature sensation through tcMEP and SSEP.

As we see a decrease in conduction, we alert the surgeon. From there, the discussion of a pause to look for recovery, changing approach, or stopping ablation, early-stage post-op therapeutics, etc., are all part of the conversation.

But before we get to that point, we might help better assess the site to be lesioned. By using Quantified EMG data, we might help approximate the distance to specific motor areas.

What might those parameters look like? Here's what was retrospectively looked at by Sapir and Korn:

"Quantified EMG data were collected in 11 patients suffering from intractable cancer pain. The threshold range for evoking motor activity was 0.3 to 1.2 V. Stimulation artifacts were detected from trapezius muscles even at the lowest stimulation intensity, while thenar muscles were found to be maximally sensitive and specific. The minimal stimulation intensity difference between the motor and the sensory threshold, set as “Δ-threshold,” was 0.26 V, with no new motor deficit at 3 days or 1 month postoperatively."

Sapir, Yechiam & Korn, Akiva & Bitan-Talmor, Yifat & Vendrov, Irina & Berger, Assaf & Shofty, Ben & Zegerman, Alexander & Strauss, Ido. (2020). Intraoperative Neurophysiology for Optimization of Percutaneous Spinothalamic Cordotomy for Intractable Cancer Pain. Operative Neurosurgery. 19. 10.1093/ons/opaa209.

12/12/2025

BREAKING: Fl weather has hit crisis levels; locals in shambles. Seeking northern talent capable of braving the harsh conditions.

or not, if you can handle 40s at sunrise and low 70s by afternoon, let’s talk.

12/10/2025

Most managers want what's called "clean escalates." But they might actually be the reason why they never get it.

_____________________

There will inevitably be conflicts in teams.

Sometimes it's because the incentives are set up to cause it.

Other times it's because each person is doing/saying what they think is best.

And sometimes it's just a maturity problem.

What matters most in these cases is how each team member handles the conflict.

One of the worst actions to take is to complain about it. To other teammates, customers, bosses, etc.

It looks bad for the person they're complaining about as well as the person doing the complaining.

It also tends to come from a place of purposeful destruction, not to point out a problem to help find a resolution.

All managers would love for their teams to bring up these conflicts and work through them as best as possible. If there is no agreement to be had, then bring in the person with the authority to make a ruling.

When everyone is present and had a chance to give their point of view.

This is the clean escalation.

This is how people interested in getting it right, not being right, work together.

But what if the manager lets the person come to them first? Isn't letting your team vent from time to time a good thing?

Sure, occasionally.

But we have to be conscious of not setting unwanted norms. Norms where complaining about someone to their boss is accepted and goes without consequences.

It's one of the elements needed for a strong culture: values, rituals, stories, and consequences.

Consequences don't always mean a smack on the wrist. It might look more like a redirect in this case.

"What did Joe say when you brought this to his attention?"

A simple question with the inference as to the way things work around here. We have conversations and work amongst ourselves.

Any unresolved conflicts are then mutually agreed upon to escalate, but only if needed.

No surprises. No politicking. No complaining behind someone's back.

It happens at every level of an organization, and it's everyone's responsibility to practice clean escalations and for managers to be consistent with consequences that shape culture.

12/08/2025

Selective hypoglossal nerve stimulation seems to be a great option in patients with obstructive sleep apnea. Maybe hashtag can take it further?

What might not be totally obvious, unless you're looking at it, is the rate of patients with bilateral innervation from the hypoglossal nerve.

Somewhere around 40%-50%.

What, if any, difference might this make?

On the upside, maybe bilateral tongue movement and bilateral tongue base opening could result in better outcomes?

Your breathing hole ends up getting wider on both sides through B activation.

- Would that help anyone?

- Would that help patients with pronounced collapse at the soft palate during drug-induced sleep endoscopy?

- Would it be helpful to find a certain ratio to forgo bilateral hypoglossal lead placement (if that proves to be helpful in a subset of patients)?

On the downside, maybe B innervation poses a higher risk for those with atypical trigeminal neuralgia?

A small subset, for sure, I just happened to see that case study. But there are some other groups that might fall into similar considerations for the group.

This might be a fruitful talk to have with your surgeons.

If discussions with your ENT doc lead to this type of exploration, here's what it might look like for you.

Neuromonitoring step 1️⃣

Look for activity in the retractors (hyoglossus and styloglossus muscles) and protrusors (horizontal and oblique genioglossus muscles).

Neuromonitoring step 2️⃣

Look for activity in the contralateral muscles that have an amplitude of greater than 10% of the ipsilateral muscles (more research is needed for the "best" ratio)

Neuromonitoring step 3️⃣

Keep usable records and follow up with your surgeon for outcomes.

Is anyone out there already monitoring B muscle groups... and for what reasons?

12/05/2025

3 interview questions I've asked people in the past that grade your level of experience beyond years in the field.

1. Tell me a topic that you could give me a 5-minute presentation on in our field that's going to teach me something new.

Here, I'm looking to see what area you chose and how deep you can go.

I might ask follow-up questions like:

- what would the outline of the talk look like?

- what would be the one to three big ideas?

- how would you adjust it for a customer presentation, not an interview?

2. Tell me something poorly understood by a customer using our service?

Here, I'm looking for your understanding of probability, not protocols.

Can you call to question something we hold as gospel, or something we need to at least consider more?

From there, I'm going to ask you how you went about expressing that point of view and level of success to effect change.

3. What changes have you seen in your time in the field and what do you think is coming?

I like to look for long term relationships. So I want someone that thinks along the lines of not just being able to do the thing, but to be able to do the thing right.

That might change over time.

I'm looking to see how you're keeping up and preparing.

12/03/2025

LTM EEG for diagnostics is hard enough with it's file size. As we see EEG complement new therapies, we might find ourselves is situations where we monitor for weeks or months.

Think what the apple watch did to BP monitoring.

12/01/2025

IONM's primary goals are to prevent injury and map structures. But what additional benefits might we find?

When we have changes that recover, we might hang that under the "prevention" side of things.

It would be hard to find too many cases where the patient woke up with a deficit that was more than transient. Usually undetectable, if anything at all.

The chances of post op deficits go up in partial or no recovery of signals.

There are cases that do not fully recover, as well as cases where the deficits are mild it might be hard to detect until things get worse.

As this paper notes, we might be able to help select groups that are better suited for early intervention after the surgery to have better outcomes in the long run. Things like physical therapy or medications.

The authors came to that conclusion in a paper titled "The role of intraoperative neuromonitoring in preventing lesions of the spinal accessory nerve during functional neck dissection."

The use of IONM during lymphectomy of the II, III, IV, and V laterocervical lymph nodes, at least to my knowledge, is not common.

In this study (small sample, retrospective), they found monitoring to be useful for the prevention of temporary and permanent deficits and the detection of groups better served with earlier therapeutic intervention.

11/28/2025

Why "I don't get involved in company politics" might be a misguided position...

When I've heard this in the past, it was typically used to mean that the person didn't want to have to schmooze or put others down to find individual prosperity.

Seems noble enough.

But the way the company operates is guided by its culture, and as the saying goes...

"Politics are downstream to culture."

Culture trumps politics.

While general culture is typically driven from the top down, local culture has more bottom-up influence.

It's being part of this local culture that influences change, or holds onto past norms in times of change.

This form of active politics involves strengthening what's good for the local team. If it is in line and supported by the corporate culture in place, it works against the influence of individuals politicking for themselves.

"We over me" becomes part of the local culture when everyone is involved.

11/27/2025

Tough economics shine a light on who has a victim or survivor mentality.

Victims shut down and let doubts in. Survivors get into a state of action and think about planning.

But there's more to the story than a person's natural proclivity to be one or the other, or who tends to have a more external vs internal locus of control.

It's a progression, not one or the other.

Here, I'll just be referring to life at work and how understanding this helps managers be better at the leadership part of their role.

___________

A victim's mentality stems from a breakdown or betrayal of trust, which most often occurs in situations where people have experienced a negative experience.

Leaders can limit the negative experiences on the front side through good communication, expectations, goals, providing a space for failure, and continued emphasis on problem solving, but not always.

This is all about setting the right culture.

On the back side of any breach of trust, a leader can always have an impact.

If the person is acting with emotions of defeat and a sense of being powerless, a firm reminder that "we don't have victims here" makes matters worse.

That's making a statement, just like a policy. It's treating people as things to be managed and doing so when a person is vulnerable.

Instead, lead.

Reiterate the "we" in any next steps, showing the support backed by trust.

Find areas we can control and focus there. It might be small wins at first.

Call out the actions that lead to change. It feels good to celebrate wins, and here it's about a change in perspective in what's possible.

This helps move to survival mode, where the person is more sure of their influence on the situation going forward.

Eventually, hopefully, we get to the thriver stage, where the person has a sense of being stronger for going through it.

And as each person gets through the stages, the chances of spending time in the emotional state of victim becomes less likely.

And so if managers want a team of resilience with a high internal locus of control, then it's on them to create that culture, work with their people, and make time for their leadership responsibility and not just their manager responsibilities.

Because the manager who complains about their team's weak adaptive nature, or inability to overcome challenges, and does nothing to help, is acting out as a victim themselves.

11/25/2025

Things to consider if your case tomorrow is booked for "separation of conjoined spinal cords in symmetrical pygopagus twins"

This is the case that everyone and no one wants to be assigned to.

It's going to be long.

There will be unknowns.

The stakes are high.

So, what are you considering the night before?

1) You'll want to be extra prepared with supplies. This is going to be a huge case. Not only is it 2 patients at once, but you'll want to really cover muscle groups per individual nerve root. Plus, there's the chance that this thing gets staged and you'll need another set per patient.

Come with your trunk full.

2) While you're looking at your supplies, realize there will be 2 lefts and 2 rights. You'll need to plan to be ready with electrode assignments out of the norm.

3) Try to work out a divide-and-conquer plan with the other SNP. You could do this one solo but really should work to get another person there (not a trainee). There will be 2 machines going at once, so you'll want to plan out cadences, adjust audio (if being used), and awareness of what the other person is doing. Be clear on who is calling what and for which kid.

4) If you don't already, you'll really want to brush up on stimulation and spread. The surgical team will really be leaning heavily on you to identify nerve roots. As in, which individual muscle(s), which kid, and at what thresholds.

5) Individual EAS muscle might be hard to distinguish, maybe even identify. Use electrodes and stimulate at a low level to help identify any circular muscle contraction. A BCR might be helpful not only to monitor but also to distinguish between baby A and B.

6) What else? Leave a comment.

Mahmoud, M.A., Elshawady, S.B., Korkar, G.H. et al. Separation of conjoined spinal cords in symmetrical pygopagus twins using intraoperative neuromonitoring: pearls and pitfalls. Childs Nerv Syst 39, 1949–1955 (2023).

Intraoperative Neuromonitoring

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