Introduction: Electrophysiological monitoring techniques allow assessment of spinal cord sensory pathways, motor pathways, and spinal root function. Recording of these parameters after spinal cord injury or during spinal column or spinal cord operative procedures (intraoperative monitoring) has the potential to evaluate the integrity of the sensory and motor pathways and spinal roots in real-time fashion. Theoretically, alterations in established recordings during spinal cord/spinal column surgery implicate an impending spinal cord injury -- an injury that could potentially be prevented to help assure a better outcome following surgery.

Methods: A National Library of Medicine (PubMed) computerized literature search from 1966 to 2016 was undertaken, revealing 82 articles on the diagnostic and therapeutic effect of intraoperative monitoring. Using standard guidelines methodology, articles were assigned classes of evidence (I, II, or III.) The evidence was then synthesized into recommendations of Level I, III, and III, corresponding to the designated classes of evidence.

Results: Intraoperative electrophysiological monitoring recording during spinal surgery is a reliable and valid diagnostic adjunct to assess spinal cord integrity and is recommended if utilized for this purpose. Motor evoked potential recordings are superior to SSEP recordings during spinal surgery as diagnostic adjuncts. Electrophysiological monitoring, including SSEP and MEP recordings, during spinal surgery has no therapeutic relationship with neurological outcome and is not recommended for this purpose. There is no evidence that the expense of IOM and its interpretation during spinal column/spinal cord surgery justifies its use in attempting to prevent iatrogenic spinal cord injury.

Conclusions: The use of intraoperative monitoring, while an effective diagnostic adjunct, does not appear to alter patient outcomes following spinal column or spinal cord surgery. In light of the existing evidence, intraoperative monitoring should NOT be considered standard of care.

Patient Care: Intraoperative monitoring has legitimate diagnostic utility, without proven therapeutic efficacy. This AANS/CNS endorsed guidelines document serves to protect practitioners from erroneous standards of care proposed by vested organizations.

Learning Objectives: A great deal has been written on the topic of electrophysiological monitoring and spinal cord function. Several professional organizations including the American Academy of Neurology and the American Association of Neuromuscular and Electrodiagnostic Medicine consider electrophysiological monitoring during spinal column or spinal cord surgery to represent the “standard of care.” This review is intended to examine the medical evidence on this important topic and to generate practice parameters by and for the operating spinal surgeon.

References: See attached manuscript.