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Different intraoperative neurophysiological monitoring techniques assess the function of the brain, brainstem, spinal cord, cranial nerves, and peripheral nerves during the procedure. They are immensely valuable in the detection and prevention of neurological insult. Intraoperative monitoring is now becoming part of standard medical practices and routinely used during many surgical procedures, including the risk of neurological injury. IONM employs a wide variety of physiological principles, each with a unique application and frequently used together in the same surgery, leading to improved patient outcomes. As the benefits of monitoring become apparent, the use of different neuromonitoring techniques during the additional surgical procedure has expanded. This activity reviews the different modalities of neurophysiological monitoring, their indications, and contraindications. This activity highlights the interprofessional team's role in evaluating and improving care for patients in providing high-quality peri-operative care to detect and prevent neurologic injuries. Objectives: Identify the indications for intraoperative neurophysiological monitoring. Describe the different techniques of intraoperative neurophysiological monitoring. Explain the importance of intraoperative neurophysiological monitoring to detect and prevent neurological injury. Review the importance of effective communication and close cooperation between interprofessional teams in providing high-quality peri-operative care to detect and prevent neurologic injuries. Access free multiple choice questions on this topic.

Intraoperative neurophysiological monitoring (IONM) helps assess the integrity of neural structures and consciousness during surgical procedures. It includes both continuous monitoring of neural tissue as well as the localization of vital neural structures. The goal of IONM is to identify intraoperative neural insults that allow early intervention to eliminate or to significantly minimize irreversible damage to the neurological structure and prevent a postoperative neurologic deficit. The use of neurophysiological monitoring during surgical procedures requires specific anesthesia techniques to avoid interference and signal alteration due to anesthesia. Different modalities of intraoperative neurophysiological monitoring (IONM) are available, each monitors a specific neural pathway, and they are: Evoked potentials including somatosensory evoked potential (SSEP), motor evoked potential (MEP), brainstem auditory evoked potential (BAEP), visual evoked potential (VEP) Electroencephalography (EEG) Electromyography (EMG) Multimodal intraoperative neuromonitoring (IONM) is recommended as an effective way to avoid permanent neurologic injury during surgical procedures.[1]

The overall risk of intraoperative neurophysiological monitoring (IONM) is low. Electrical safety is paramount in the operating room. Patients under anesthesia cannot report discomfort or pain; so, it is vital to ensure that IONM equipment is checked before a safe operation. Monitoring equipment malfunctioning can lead to local skin burns and other serious complications. An additional reported risk is seizure activity, high frequency (50 to 60 Hz) electrical brain stimulation can lead to seizure activity due to abnormal neuronal discharges.[15] Masseter muscles' stimulation and forceful jaw movement during MEP monitoring can lead to a tongue laceration, tooth fracture, or mandible fracture. These risks can be avoided by using bite blocks.[7] In rare cases, patients may experience tingling, bruising, soreness, and swelling at the needle insertion sites.[16] Invasive electroencephalogram monitoring during epilepsy surgery may also lead to adverse events; the risk is low, but the most commonly reported incidents are intracranial hemorrhage, superficial infection, cerebral infections, and elevated intracranial pressure.[14]

Intraoperative neurophysiological monitoring (IONM) is considered the standard of care during many procedures, including spinal, intracranial, and vascular surgeries, where there is a risk of neurological damage.[18] [Level 1] Effective communication and close cooperation between multidisciplinary teams, including intraoperative neuromonitoring (IONM) technician, a neurophysiologist, anesthesiology, and surgery team, is required for high-quality perioperative care to detect and prevent neurologic injuries. Enhancing communication between multidisciplinary teams increases the safety, quality, efficacy, and efficiency of perioperative care by decreasing adverse events and improving perioperative outcomes.[19] [Level 1] Various modalities of neurophysiological monitoring are used to monitor neural structures during different types of surgery. IONM team collaborates with the surgical and anesthesiology team to optimize signal acquisition and provide real-time analysis, interpretation, and timely communication of signal changes, which allows the surgeon to operate safely and avoid neural tissue injury. Continuous IONM is a helpful real-time adjunct to detect malpositioning related nerve injury and anesthesia-related signal changes. The anesthesiology team relies on the IONM team to identify physiological deterioration. It allows the anesthesiology team to adjust their anesthetic dosing to provide a condition that supports neurophysiological monitoring.