http://www.intraoperativeneuromonitoring.com/

Intraoperative Neuromonitoring, Orlando, FL (2025)

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."

10/16/2025

Reach out to me if you're a and interested in a traveler position.

10/15/2025

Case study: what to monitor for radical hysterectomy.

This group decided to use a catheter electrode to monitor the integrity of the hypogastric or pelvic nerve.

Modality #1 - Bulbocavernosus Reflex (BCR)

They were not able to obtain a response from the electrode.

Modality #2 - tcMEP

They did record a CMAP. Not the prettiest wave. Good to have an understanding of onset latency to help determine the wave.

__________

This case study showed a True Positive.

Not sure what the surgical intervention or assumed cause of injury, but now that we know it can be used to identify nerve injury, the next step is seeing if we can prevent it through intervention.

I'd also like to compare against the more commonly used BCR setup and external sphincter motor responses.

10/13/2025

"Do you use neuromonitoring for TAAA repair, and if not, what are you missing out on?"

That's a second question that the Aortic Association could ask their surveyed respondents after their initial question, "Do you use neuromonitoring during endovascular and/or open TAAA surgery?

The first question results are seen in the graph below.

You can see MEP/SSEP monitoring is used 60% of the time in open and 25% in endovascular.

CSF drainage is pretty much routine, and NIRS in seconds.

So, why might the 40% and 75% not using IONM consider it if the surgical protocol includes CSF drainage, distal aortic perfusion, and reattachment of intercostal arteries?

Here's a snippet from the second study listed below:

"The present series shows that MEP monitoring is a trustworthy navigation system, allowing the surgeon to be informed about the function of the spinal cord and to adjust strategies in case spinal cord ischemia occurs. However, and very unfortunately, this does not always guarantee the prevention of spinal cord injury, as illustrated by our patients in whom we were not able to restore spinal cord function despite all possible measures. On the other hand, it should be noted that MEP monitoring played a crucial role in a substantial number of cases, inducing actions to restore spinal cord perfusion successfully and subsequently prevent paraplegia."

So it's not 100%. But nothing is.

What it allows for is a different look and way to stay updated that allows the reduction in the incidence of a catastrophic event.

And that's when IONM tends to provide the best value.

Thomas Schachner and others, Practice of Neuromonitoring in open and endovascular thoracoabdominal aortic repair – An international expert-based modified Delphi consensus Study, European Journal of Cardio-Thoracic Surgery, 2023;, ezad198,

Michael J. Jacobs, Werner Mess, Bas Mochtar, Robbert J. Nijenhuis, Randolph G. Statius van Eps, Geert Willem H. Schurink, The value of motor evoked potentials in reducing paraplegia during thoracoabdominal aneurysm repair, Journal of Vascular Surgery, Volume 43, Issue 2, 2006, Pages 239-246, ISSN 0741-5214, .

10/09/2025

Following up on a previous post looking at using inexpensive sticker electrodes, there's obvious cases where that technique is a no go. But these more extreme cases should also come with some additional discussions.

1. Don't just use the tEMG to identify the RLN at first, map it throughout the case.

2. Consider using ongoing monitoring of the nerve. With these larger cases, it's not costing you any new exposure to add a stimulating C-clamp electrode to run potentials throughout the case.

3. MEPs might be a helpful secondary modality... at least worth mentioning. Harder to control the recording of any muscle near the surface electrode on the tube, which opens the door for false negatives. At the same time, anesthetics might cause incidences of false positives.

Farahani, P. K. (2025). Massive multinodular goiter causing airway compression: A case series. International Journal of Surgery Case Reports, 111991.

10/08/2025

Low cost technique for thyroidectomies. Let's discuss...

The authors utilized the commonly used tube with electrodes imbedded for RLN monitoring. At the same time, they place surface electrodes by visualized the vocal cords through the use of laryngeal ultrasonography.

The question they were looking to answer was can we get similar results with much more inexpensive supplies.

The results on 216 patients... not bad. (see the image)

The one variable that seemed to increase false results was a higher body mass index (BMI). They suggested < 25 as the range where each technique resulted in similar accuracy (94.6%).

One question that came to mind was the use of needle electrodes as a superior means of recording EMG with a similar/lower price point. Especially in patients with BMI > 25.

But due to the location of the carotid artery and jugular vein, I'd be hesitant to consider that a great technique.

What are your thoughts?

Fung, M. H. M., Cheng, C. C., Luk, Y., & Lang, B. H. H. (2025). Laryngeal ultrasound-guided adhesive transcutaneous electrodes versus conventional endotracheal electrodes for intraoperative neuromonitoring during thyroid and neck surgery. Surgery, 109709.

10/07/2025

“I believe that what we become depends on what our fathers teach us at odd moments, when they aren't trying to teach us. We are formed by little scraps of wisdom.”

This is one of the reasons leading remote teams is hard.

We pick up on so much from other human beings than what's being said.

Email/text get the job done for the task at hand, but usually misses on the "little scraps."

The best alternative I've found is consistent one on ones.

And it's a two way street. Both get the opportunity to learn.

_____________

Foucault's Pendulum (yes, the quote is dated by the implications associated with "fathers." I'm glad we're past that)

09/30/2025

This neuromonitoring study asked surgeons about their "feelings." Seems like a safe territory to explore, right? Right?

If we're being honest, some surgeons see us as a nuisance. All the needles, wires, and blips and beeps.

But then again, there are others that will cancel their case if they don't get the monitoring they can trust.

But usually, we're right smack in the middle: "Glad to see you... how was your weekend... hope I don't have to hear from you today."

Everyone knows it's only a matter of time before we have to announce a change, or why else would we be there?

But every time, everyone is hoping for silence.

That is, of course, it's one of those cases where there is a section of the procedure where neuromonitoring is called for discussion under new conditions.

- Clamping during a CEA
- Pedicle screw stimulation
- Bony decompression during Arnold Chiari decompression

This study was done during temporary clamping for an aneurysm.

Here're the results:

"Our study also demonstrated that IOM provides the surgeon with more confidence concerning the procedures' outcome for the patient (Krieg et al., 2012; Gl€asker et al., 2006).

There were no occasions in which IOM had a negative impact on a surgeon's confidence.

By contrast, there was a discrepancy between the positive effects on the sense of security (63.8%) and the impact on objective surgical outcomes (19.1%). The latter of which is a function of the overall surgical performance with IOM as one of the cornerstones within the intraoperative decision-making framework. The surgeon's sense of security, however, is highly variable and may be unfounded during the course of surgery. A facet of the surgeon's persona, some may be unsure even without any clear indication of intraoperative injury or insult; it is in these cases that IOM may deliver a much-needed confirmation of the absence of injury and thus provide a pivotal sense of security."

Not bad scores, in my estimation. There are some other surgeries where they might not have been so high, some may be a little better. But this seems like a reasonable spot on average.

Thoughts on what surgeries might score the lowest or best?

Lea Baumgart, Arthur Wagner, Anne-Sophie Dorier, Doris Droese, Amir K. Aftahy, Maria Wostrack, Sebastian Ille, Bernhard Meyer, Sandro M. Krieg,
Predictive value of IOM in clipping of unruptured intracranial aneurysms – A prospective study from the surgeon's point of view, Brain and Spine, Volume 3, 2023, 101759, ISSN 2772-5294

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