Training activity information
Details
Produce plans for intraoperative neuromonitoring for spinal surgery to include cases that require:
- Lower limb somatosensory evoked potentials
- Upper limb somatosensory evoked potentials
- Lower limb motor evoked potentials
- Upper limb motor evoked potentials
- Upper limb free-run electromyography
- Lower limb free-run electromyography
Type
Entrustable training activity (ETA)
Evidence requirements
Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion.
Reflection at multiple timepoints on the trainee learning journey for this activity.
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
What does success look like?
- Have you identified what is expected of you in relation to producing comprehensive plans for spinal surgery, including cases requiring upper and lower limb somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), and free-run electromyography (EMG)?
- How do the learning outcomes apply, specifically regarding the integration of nervous system anatomy and physiology into the monitoring strategy?
- What does a complete and robust monitoring plan look like for a specific surgical procedure, and have you discussed these expectations for recording and stimulation sites with your training officer?
What is your prior experience of this activity?
- What do you already know about the anatomy of the central and peripheral nervous system, including innervation targets and blood supply?
- What challenges do you anticipate when adapting modalities (monitoring and/or mapping) to a complex surgical plan, and how might you handle them?
- Do you recognise the scope of your own practice and know when to seek help from a senior colleague for high-risk surgical cases?
What do you anticipate you will learn from the experience?
- What specific skills do you want to develop related to determining stimulation and recording parameters tailored to individual surgical steps?
- What insights do you hope to gain regarding the interplay between the surgical approach and neural risk?
What additional considerations do you need to make?
- Have you consulted actions identified from previous planning exercises or observations in the operating room?
- What critical information, such as the specific surgical approach, do you need to consider before starting?
In action
During the activity is anything unexpected occurring?
- Are you noticing gaps in the surgical referral or a sudden change in the planned surgical approach (e.g., from posterior to anterior) that requires an immediate revision of the monitoring strategy?
- Are you identifying limitations in standard SSEP or MEP montages for a specific patient’s anatomy or deformity that you hadn’t initially considered?
How are you reacting to the unexpected development?
- How are you adjusting the selected modalities or recording/stimulation sites in the moment to ensure comprehensive coverage of the neural pathways at risk?
- Are you seeking immediate clarification from the surgical team or a senior colleague regarding the specific levels of instrumentation or decompression?
What is the conclusion or outcome?
- Are you successfully producing a robust and adaptable plan within your scope of practice?
- What are you learning about the nuances of planning for non-standard or complex spinal cases?
On action
What happened?
- How would you summarise the key points of your experience in producing comprehensive plans for spinal surgery, particularly those requiring upper and lower limb SSEP, MEP, and free-run EMG?
- Which specific events or interactions felt most important, such as how you integrated the anatomy and physiology of the nervous system into your monitoring strategy?
- What ‘reflect-in-action’ moments occurred where you had to adapt, such as revising the plan immediately due to a sudden change in the surgical approach or levels of instrumentation?
- How were you feeling during the planning phase, especially when ensuring the plan was robust enough for complex cases like spinal deformity correction?
How has this experience contributed to your developing practice?
- What specific learning can you take from this regarding your ability to determine individualised parameters for multi-modality monitoring?
- What strengths did you demonstrate in selecting appropriate recording and stimulation sites, and what knowledge gaps were evident regarding the interplay between the surgical approach and neural risk?
- How does this experience compare against your previous planning exercises—has your ability to integrate CNS and PNS anatomy into a monitoring strategy improved?
- Did any challenges, such as identifying the relevant neural pathways at risk, require you to seek advice from a senior colleague to ensure you were working within your scope of practice?
What will you take from the experience moving forward?
- What specific actions or ‘next steps’ will you take to support the assimilation of what you have learned, including any feedback received regarding your monitoring strategy?
- What will you do differently next time to ensure your plans are even more adaptable to dynamic surgical requirements?
- Do you need to further review the technical considerations for specific neurovascular or spinal tumour surgeries to refine your future plans?
Beyond action
Have you revisited the experiences?
- Have you reviewed your previous reflections on producing multi-modality plans for cases requiring SSEP, MEP, and free-run EMG?
- What specific actions did you identify to improve your ability to integrate the anatomy and physiology of the nervous system (e.g., blood supply, spinal nerves) into your planning?
- Have you completed the actions identified following your initial plans? For example, if you planned to review the technical considerations for specific spinal surgery approaches (e.g., anterior vs. posterior), how has this new knowledge influenced your current ability to adapt modalities and recording parameters?
- How has discussing these cases influenced your systematic approach to selecting appropriate recording and stimulation sites?
How have these experiences impacted upon current practice?
- Consider how the accumulated learning from producing IONM plans will support you in preparing for the in-persons assessments for this module.
- How has your practice in determining stimulation and recording parameters evolved? For example, can you identify instances where your foundational knowledge of innervation targets and neural risk has informed your decisions when planning for high-risk neurovascular or tumour surgeries?
- What transferable skills, such as technical logic or systematic planning, did you develop through this activity, and how will this help you adopt new monitoring strategies in the future?
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Plan and prepare for intraoperative neuromonitoring for spinal surgery |
| # 2 |
Outcome
Obtain clinical histories for patients undergoing intraoperative neuromonitoring. |
| # 3 |
Outcome
Identify other investigations and procedures required before spinal surgery is undertaken. |
| # 4 |
Outcome
Apply legislation and guidelines and manage risk in the performance of intraoperative neuro monitoring. |