Planning for Intraoperative Neuromonitoring —
Training activity: 2

Details

Identify pathological areas of interest relevant to planned spinal surgeries to determine required modalities. To include indications for:

 

• 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 the expectations for correlating pathological findings (e.g., myelopathies, scoliosis, or tumours) with required neurophysiological modalities?
• How will you determine the clinical significance of a pathology to ensure the monitoring plan is targeted?
• Have you discussed with your training officer how to prioritise modalities based on the suspected site of injury?

What is your prior experience of this activity?

• What is your current knowledge of disorders of the CNS and PNS and how they typically affect IONM recordings?
• What challenges do you anticipate in identifying relevant neural pathways at risk in complex cases like arteriovenous malformations?

What do you anticipate you will learn from the experience?

• How will this experience help you develop skills in correlating clinical history with neurophysiological risk?
• What insights do you hope to gain regarding when to use mapping versus monitoring techniques?

What additional considerations do you need to make?

• Have you reviewed your observations from previous spinal radiology reporting (e.g., MRI or bending films)?
• What patient-specific data, such as the presence of pre-existing neurological deficits, is critical to this task?

In action

During the activity is anything unexpected occurring?

• While reviewing the spinal radiology (MRI, CT), are you noticing unexpected pathologies, such as a syrinx, tethered cord, or vascular malformation, that weren’t highlighted in the referral?
• Are you encountering conflicting information between the clinical history of sensory/motor deficits and the imaging findings?

How are you reacting to the unexpected development?

• How are you prioritising different pathways (e.g., dorsal columns vs. corticospinal tract) in real-time based on these findings?
• Are you deciding to add additional modalities, such as D-waves or nerve root mapping, to better address the identified risks?

What is the conclusion or outcome?

• Are you ensuring the monitoring plan is precisely targeted to the identified pathology?
• What are you learning about correlating imaging findings with neurophysiological risk?

On action

What happened?

• How would you summarise the experience of correlating pathological findings, such as myelopathies or scoliosis, with the required neurophysiological modalities?
• Which interactions felt most important, such as reviewing spinal radiology (MRI or bending films) with a senior colleague to determine the clinical significance of a pathology?
• Were there any moments where you had to adapt your interpretation in response to identifying an unexpected pathology in the patient’s clinical history?
• What were your feelings during this process, especially when differentiating between the monitoring requirements for different disorders of the CNS and PNS?

How has this experience contributed to your developing practice?

• What learning can you take regarding your ability to correlate clinical history with neurophysiological risk?
• What strengths did you demonstrate in identifying which neural pathways were at risk for a specific disorder, and where were gaps in your knowledge evident?
• How does this experience compare to previous similar activities—has your practice in prioritising modalities based on the suspected site of injury improved?
• Did you need to seek clarification from the MDT or a consultant regarding a rare pathology to ensure your modality selection was appropriate?

What will you take from the experience moving forward?

• What specific actions will you now take, such as seeking opportunities for more expert review of complex radiology reports to enhance your analytical skills?
• How will your approach change next time if imaging findings conflict with the clinical referral?
• Do you need to further review the pathophysiology of specific spinal cord malformations to support your future determinations of required modalities?

Beyond action

Have you revisited the experiences?

• Have you reviewed your previous reflections regarding the identification of pathological areas such as myelopathies, tumours, or arteriovenous malformations? What actions did you identify to improve your ability to correlate imaging findings (e.g., MRI or bending films) with required modalities?
• Have you completed these actions? For instance, if you planned to attend a specialist scoliosis clinic or observe the reporting of spinal radiology, how did these clinical experiences change your view of the situation when determining the clinical significance of a pathology?
• Engage in professional storytelling with senior colleagues about the nuances of identifying the relevant neural pathways at risk in complex cord pathologies. How has this mutual exchange helped you better understand when to prioritise mapping over monitoring?

How have these experiences impacted upon current practice?

• Consider how your proficiency in identifying pathological risks will support your preparation for the in-person assessments for the module.
• How has your ability to correlate clinical history with neurophysiological risk developed over time? Can you now identify when a finding is beyond your scope of practice, requiring you to seek consultant input regarding a rare or ambiguous pathology?
• What transferable skills, such as diagnostic reasoning or image assessment, did you develop through this activity, and how has this informed your problem-solving in other areas of neurophysiology?

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.