Performing Intraoperative Neuromonitoring —
Training activity: 9

Details

Monitor and interpret recorded responses throughout surgical procedures for spinal, to include:

• communicating with the theatre team,
• identifying and responding to factors impacting responses
• documenting any relevant pathogenic, non-pathogenic, and neurophysiological changes when required.

For at least one the following:

• Triggered electromyography
• Free-running electromyography

Type

Developmental training activity (DTA)

Evidence requirements

Evidence the activity has been undertaken by the trainee​.

Reflection on the activity at one or more time points after the event including learning from the activity and/or areas of the trainees practice for development.

An action plan to implement learning and/or to address skills or knowledge gaps identified.

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 are the intended outcomes of this training activity?

• How do the specific learning outcomes such as recording EMG, identifying factors that impact signals, and demonstrating professional communication, contextualise your preparation for this case?
• What do you need to know about the indicative content for this module, such as the use of alarm criteria or the patterns of signal changes caused by common surgical steps, before you begin monitoring?

What specific knowledge do you need to recall or review?

• What is your current understanding of nerve root mapping and the requirements for recording high-quality EMG signals?
• How will you differentiate between non-pathological sources of changes, such as systemic effects or anaesthesia, and true neurophysiological changes while the surgery is in progress?

What do you anticipate learning from this experience?

• What specific insights do you hope to gain regarding the morphology, amplitude, and reproducibility of EMG responses during a live spinal procedure?
• How do you expect this activity to build upon your existing skills in troubleshooting recording artefacts or stimulation problems in the theatre environment?

What actions will you take to prepare for this procedure?

• Have you discussed the specific monitoring plan and your role in the theatre briefing with your Training Officer to gain clarity? What potential challenges do you anticipate, such as managing complex technical problems or the pressure of providing accurate and timely communication to the surgical team, and how will you handle them?

How do you feel about embarking on this activity?

• Are you confident in your ability to identify and document relevant changes in real-time, and what steps can you take to ensure you approach the task with the necessary focus and professional attitude?
• What resources, such as peer-reviewed evidence on identifying neurological damage, should you consult to ensure you are fully prepared?

In action

What are you doing?

• What specific aspects of the EMG signal morphology, amplitude, and reproducibility are you focusing on right now, and why are these relevant to the current surgical step?
• How are you approaching the systematic documentation of relevant changes—what decisions are you making regarding when to annotate a signal fluctuation versus when to provide an immediate verbal alert?
• How are you relating the real-time neurophysiological data to your pre-operative plan, and are you making any necessary adjustments based on the patient’s status today?
• Which parts of identifying and troubleshooting recording artefacts or stimulation problems feel intuitive in this moment, and which require more conscious technical effort?

How are you progressing with the activity?

• How effective is your current communication with the surgeon and anaesthetist in ensuring the MDT understands the status of the nerve roots?
• What challenges are you facing in differentiating between non-pathological sources of change (such as anaesthetic or systemic effects) and true pathogenic neurophysiological changes as they occur?
• What are you learning about the relationship between specific surgical mechanisms and the patterns/timing of the EMG signal changes you are observing?
• How are you successfully correlating your existing knowledge of spinal cord and nerve root mapping with the live responses on the screen?

How are you adapting to the situation?

• Are there alternative optimisation techniques you should consider to improve the signal-to-noise ratio for this specific patient if the recording environment becomes noisy?
• What support or guidance do you need from a senior colleague or your Training Officer right now to help interpret an ambiguous triggered EMG response?
• Are you ensuring that your real-time interpretation of the alarm criteria and your subsequent feedback to the team remain strictly within your prescribed scope of practice?
• How are you adjusting your communication style in response to the theatre team’s reactions or questions regarding the documented changes?

On action

What did you notice?

• How would you summarise the key points of the spinal procedure and the specific Triggered or Free-running EMG responses you monitored?
• What did you notice about the theatre team’s reaction to the neurophysiological data or alerts you provided?
• What were the most significant pathogenic or non-pathogenic changes you documented, and at what specific surgical stages did they occur?
• What did you observe regarding the reproducibility and morphology of the signals during critical moments of the surgery?

What did you learn from the activity?

• What new insights did you gain into the relationship between common surgical mechanisms and the specific patterns of EMG signal changes?
• How effectively were you able to differentiate between true neurophysiological changes and interference from anaesthetic or systemic effects?
• In what ways did your reflection-in-action (decisions made during the surgery) influence the safety of the procedure or the quality of the recorded data?
• How did this experience enhance your understanding of nerve root mapping and the application of alarm criteria in a live surgical environment?
• Were there any unexpected technical challenges with stimulation or recording artefacts, and what did you learn from troubleshooting them under pressure?
• How does this experience relate to the competencies and professional standards required for post-programme specialist practice?

What will you take from the experience moving forward?

• What areas for continued development have you identified regarding your ability to provide accurate and timely communication to the MDT?
• How can you apply the learning from this case to improve your annotation and documentation of signal fluctuations in future spinal procedures?
• What specific actions or ‘next steps’ will you now take to refine your interpretive skills for complex EMG morphology?
• What additional support or resources, such as further review of indicative academic content on iatrogenic complications, might help you enhance your monitoring practice?
• How will you modify your approach to troubleshooting stimulation problems based on the successes or difficulties encountered in this case?

Beyond action

Have you revisited the experiences?

• Have you revisited your initial experiences of monitoring triggered and free-running electromyography (EMG) across different spinal procedures?
• How has your approach to identifying non-pathological sources of change, such as anaesthetic or systemic effects, evolved since you first began interpreting these signals?
• Looking back, how has your understanding of nerve root mapping and signal reproducibility changed as you have encountered a wider variety of surgical mechanisms?
• Have you engaged in professional storytelling with colleagues regarding cases where significant EMG fluctuations occurred? How has this mutual exchange of experiences transformed your view of ‘normal’ baseline variations?

How have these experiences impacted upon your current practice?

• How has the cumulative experience of interpreting real-time EMG responses supported your ability to provide accurate and timely communication to the multidisciplinary theatre team?
• Can you identify instances where your foundational knowledge of alarm criteria and iatrogenic complications has informed your decisions in subsequent, more complex monitoring scenarios?
• How has your proficiency in troubleshooting recording artefacts and stimulation problems developed, and how does this impact the overall safety and quality of the intraoperative data you provide?
• How will the learning from these monitoring sessions support you in preparing for your in-person assessments regarding the risks and benefits of the monitoring approach?

How might these experiences contribute towards your future practice?

• What transferable skills, such as rapid clinical reasoning, technical problem-solving, and professional leadership within a high-pressure environment, are you developing through this activity?
• How will your commitment to meticulous documentation and annotation of signal changes continue to be a cornerstone of your practice as a specialist?
• In what ways will your experience in identifying and responding to factors that impact EMG signals inform your approach to adopting new monitoring technologies or protocols in the future?
• What clear actions will you take to continue developing your expertise in interpreting complex neurophysiological changes to effectively prevent or reduce neurological damage in future surgical cases?

Relevant learning outcomes

#	Outcome
# 1	Outcome Follow the pre-operative plan for intraoperative neuromonitoring for spinal surgery, making any necessary adjustments based on information available on the day of monitoring.
# 3	Outcome Record free running and/or triggered electromyography during intraoperative neuromonitoring for spinal surgery.
# 4	Outcome Identify and respond to factors that impact intraoperative neuromonitoring for spinal surgery including technical problems and physiological effects.
# 5	Outcome Identify, communicate and document relevant changes noted in intraoperative neuromonitoring for spinal surgery.
# 7	Outcome Demonstrate effective and professional communication skills with the multidisciplinary theatre team.