Planning for Intraoperative Neuromonitoring —
Training activity: 3

Details

Assess the requirement for pre-operative baseline neurophysiology for spinal surgeries including practicalities of performing for patients requiring:

 

• Lower limb somatosensory evoked potential
• Upper limb somatosensory evoked potential
• Lower limb motor evoked potentials
• Upper limb motor evoked potentials

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 assessing the value and practicalities of pre-operative baseline studies?
• How are you determining which patients (e.g., those with motor disturbances or sensory loss) require baseline testing to establish pre-operative functional status?

What is your prior experience of this activity?

• What do you know about EP and EMG techniques and the types of potentials that can be obtained in a clinical setting?
• What challenges, such as patient physical limitations or co-morbidities like diabetes, might make obtaining a baseline difficult?

What do you anticipate you will learn from the experience?

• How will you refine your skills in interpreting baseline data to predict intraoperative signal stability?
• What insights do you hope to gain regarding the prognostic value of pre-operative neurophysiology?

What additional considerations do you need to make?

• Have you reviewed actions from previous pre-operative clinic attendances?
• Does the patient have any implanted devices that might interfere with recordings?

In action

During the activity is anything unexpected occurring?

• During the baseline assessment, are you seeing significantly abnormal or unstable waveforms that don’t seem to correlate with the patient’s known pathology?
• Are you encountering unexpected patient factors, such as extreme anxiety or physical limitations, that make standard EP or EMG acquisition difficult?

How are you reacting to the unexpected development?

• Are you adapting your communication or recording technique in the moment to ensure the patient is comfortable and the data is valid?
• How are you documenting these baseline variations to inform the intraoperative team about potential signal instability?

What is the conclusion or outcome?

• Are you successfully determining the value of the baseline study for this specific patient?
• What are you learning about the prognostic value of pre-operative neurophysiology?

On action

What happened?

• How would you summarise the experience of assessing the value and practicalities of performing pre-operative baseline studies, particularly for patients with existing motor or sensory deficits?
• Which interactions felt most significant, such as identifying patient-specific co-morbidities like cerebral palsy or diabetes that made obtaining a baseline challenging?
• Did you have to adapt your recording technique during the baseline assessment to manage a patient’s physical limitations or anxiety?
• How were you feeling after the assessment, and did you feel the baseline data was valid enough to establish the patient’s functional status?

How has this experience contributed to your developing practice?

• What learning can you take regarding the prognostic value of pre-operative baseline data?
• What strengths did you demonstrate in interpreting baseline signals, and what knowledge gaps were evident regarding the interpretation of unstable waveforms?
• How has your practice in managing patients with implanted devices or metalwork improved compared to your earlier training?
• Did you need to seek clarification from a supervisor regarding the significance of an abnormal baseline finding to ensure signal stability could be predicted intraoperatively?

What will you take from the experience moving forward?

• What specific ‘next steps’ will you take to support the assimilation of what you have learned about predicting intraoperative signal stability?
• Is there anything you would do differently next time to better manage the logistics of baseline testing within your department’s workflow?
• Do you need to attend more pre-operative clinics to observe the clinical assessment process and refine your understanding of pre-operative functional status?

Beyond action

Have you revisited the experiences?

• Have you reviewed your actions from previous reflections on assessing the value of pre-operative baseline studies? What specific actions did you identify to improve your assessment of a patient’s pre-operative functional status?
• Have you completed these actions? For example, if you reviewed the MSc indicative content on disorders that affect recordings (e.g., cerebral palsy, diabetes), how did this help you predict intraoperative signal stability in your most recent assessment?
• Engage in professional storytelling with peers regarding the practicalities of performing baselines for patients with significant physical limitations. How has this changed your approach to patient-centred care and technical troubleshooting?

How have these experiences impacted upon current practice?

• Consider how the accumulated learning from assessing baseline requirements will support you in the in-person assessments for this modules.
• How has your practice in interpreting baseline data developed? For example, how does your foundational knowledge of pre-operative studies help you distinguish between pathological signal changes and technical limitations?
• What transferable skills, such as prognostic evaluation or clinical assessment, did you develop, and how will this help you evaluate new diagnostic technologies 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.
# 6	Outcome Demonstrate effective and compassionate communication skills with all stakeholders, including patients and the multi-disciplinary team.