Practice guidelines for the supervising professional: intraoperative neurophysiological monitoring.

The American Society of Neurophysiological Monitoring (ASNM) was founded in 1989 as the American Society of Evoked Potential Monitoring. From the beginning, the Society has been made up of physicians, doctoral degree holders, Technologists, and all those interested in furthering the profession. The Society changed its name to the ASNM and held its first Annual Meeting in 1990. It remains the largest worldwide organization dedicated solely to the scientifically-based advancement of intraoperative neurophysiology. The primary goal of the ASNM is to assure the quality of patient care during procedures monitoring the nervous system. This goal is accomplished primarily through programs in education, advocacy of basic and clinical research, and publication of guidelines, among other endeavors. The ASNM is committed to the development of medically sound and clinically relevant guidelines for the performance of intraoperative neurophysiology. Guidelines are formulated based on exhaustive literature review, recruitment of expert opinion, and broad consensus among ASNM membership. Input is likewise sought from sister societies and related constituencies. Adherence to a literature-based, formalized process characterizes the construction of all ASNM guidelines. The guidelines covering the Professional Practice of intraoperative neurophysiological monitoring were initially published January 24th, 2013, and subsequently that document has undergone review and revision to accommodate broad inter- and intra-societal feedback. This current version of the ASNM Professional Practice Guideline was fully approved for publication according to ASNM bylaws on February 22nd, 2018, and thus overwrites and supersedes the initial guideline.

Perils of intraoperative neurophysiological monitoring: analysis of "false-negative" results in spine surgeries.

BACKGROUND CONTEXT: Although some authors have published case reports describing false negatives in intraoperative neurophysiological monitoring (IONM), a systematic review of causes of false-negative IONM results is lacking. PURPOSE: The objective of this study was to analyze false-negative IONM findings in spine surgery. STUDY DESIGN: This is a retrospective cohort analysis. PATIENT SAMPLE: A cohort of 109 patients with new postoperative neurologic deficits was analyzed for possible false-negative IONM reporting. OUTCOME MEASURES: The causes of false-negative IONM reporting were determined. MATERIALS AND METHODS: From a cohort of 62,038 monitored spine surgeries, 109 consecutive patients with new postoperative neurologic deficits were reviewed for IONM alarms. RESULTS: Intraoperative neurophysiological monitoring alarms occurred in 87 of 109 surgeries. Nineteen patients with new postoperative neurologic deficits did not have an IONM alarm and surgeons were not warned. In addition, three patients had no interpretable IONM baseline data and no alarms were possible for the duration of the surgery. Therefore, 22 patients were included in the study. The absence of IONM alarms during these 22 surgeries had different origins: "true" false negatives where no waveform changes meeting the alarm criteria occurred despite the appropriate IONM (7); a postoperative development of a deficit (6); failure to monitor the pathway, which became injured (5); the absence of interpretable IONM baseline data which precluded any alarm (3); and technical IONM application issues (1). CONCLUSIONS: Overall, the rate of IONM method failing to predict the patient's outcome was very low (0.04%, 22/62,038). Minimizing false negatives requires the application of a proper IONM technique with the limitations of each modality considered in their selection and interpretation. Multimodality IONM provides the most inclusive information, and although it might be impractical to monitor every neural structure that can be at risk, a thorough preoperative consideration of available IONM modalities is important. Delayed development of postoperative deficits cannot be predicted by IONM. Absent baseline IONM data should be treated as an alarm when inconsistent with the patient's preoperative neurologic status. Alarm criteria for IONM may need to be refined for specific procedures and deserves continued study.

Quality assurance and performance improvement in intraoperative neurophysiologic monitoring programs.

Quality assurance (QA) as it relates to intraoperative neurophysiological monitoring (IONM) can be defined as the systematic monitoring, evaluation, and modification of the IONM service to insure that desired standards of quality are being met. In practice, that definition is usually extended to include the concept that the quality of the IONM service will be improved wherever possible and, although there are some differences in the two terms, in this article the term QA will be understood to include quality improvement (QI) processes as well. The measurement and documentation of quality is becoming increasingly important to healthcare providers. This trend is being driven by pressures from accrediting agencies, payers, and patients. The essential elements of a QA program are described. A real-life example of QA techniques and management relevant to IONM providers is presented and discussed.