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The scientific practice of neuromonitoring takes place in the surgical suite (OR). It aims to 1) reduce the risk to the patient of iatrogenic damage to the nervous system, and/or 2) provide functional guidance to the surgeon. To accomplish this, a specially trained member of the surgical team, for example a neurophysiologist, obtains and co-interprets triggered and spontaneous electrophysiologic signals from the patient as their surgery proceeds. Patients who benefit from neuromonitoring are those undergoing surgeries which involve the nervous system or which pose risk to it. Neuromonitoring is also known as surgical neurophysiology, intraoperative neurologic monitoring, or simply intraoperative monitoring. Acronyms include IOM and IONM.
Additional recommended knowledge
Licensure - Certification - Credentialing
In the US, IONM licensure has not been legislated at the state or federal level. Issues of licensure are discussed in ASET's 68 page White Paper on Occupation Regulation. Worldwide, there are at least two private certifications available: the technologist level CNIM and the professional level D.ABNM. Though not governmentally regulated, certain health care facilities have internal regulations pertaining to neuromonitoring certifications. The more fundamental issue is that demand for trained intraoperative neurophysiologists continues to be greater than their number (2007).
Certification for Neurophysiological Intraoperative Monitoring (Technologist Certification)
The CNIM  is awarded by the American Board of Electroencephalographic and Evoked Potential Technicians . As of 2007-02, minimum requirements include 1) a B.A., B.S. or another health care credential, and 2) an experience base of 100 surgeries. ABRET has scheduled for 2008 major changes to these requirements. The $350, 250 question, 4 hour multiple choice written exam is offered twice a year.
Diplomat of the American Board of Neurophysiologic Monitoring (Professional Board Certification)
The D.ABNM  is awarded by the American Board of Neurophysiological Monitoring . As of 2007-02, the minimum requirements include 1) an M.S. or M.A. in a health science related field, Most have an MD, PhD, AuD, ScD or a DC. 2) an experience base of 300 surgeries that spans at least 3 years of primary responsibility, and 3) two surgeon-signed attestation forms. The exam includes a written portion, which must be passed first, and an oral portion. The $600, 250 question, 4 hour written exam is offered twice a year, as is the $800 oral exam. As 2007-02, there are 104 D.ABNM certified individuals.
Neuromonitoring employs various electrophysiologic modalities, such as extracellular single unit and local field recordings, SSEP, TCeMEP, EEG, EMG, and ABR. For a given surgery, the set of modalities used in depends on which neural structures are at risk.
In general, a trained neurophysiologist or technologists attaches a computer system to the patient using stimulating and recording electrodes. Interactive software running on the system carries out 2 tasks. The system 1) selectively activates stimulating electrodes with appropriate timing, and 2) processes and displays the electrophysiologic signals as they are picked up by the recording electrodes.
See video of the equipment used 
The neurophysiologist can thus observe and document the electrophysiologic signals in realtime in the operating during the surgery. The signals change according to a various factors, including anesthesia, tissue temperature, surgical stage, and tissue stresses. Various factors exert their influence on the signals with various tissue-dependent timecourses. Differentiating the signal changes along these lines - with particular attention paid to stresses - is the joint task of the surgical triad: surgeon, anesthesiologist, and neurophysiologist.
Transcranial Doppler Imaging is becoming more widely used to detect vascular emboli. TCDI can be used in tandem with EEG during vascular surgery.
IONM techniques have significantly reduced the rates of morbidity and mortality without introducing additional risks. By doing so, IONM techniques reduce health care costs.
Patients benefit from neuromonitoring during certain surgical procedures, including:
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|This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Neuromonitoring". A list of authors is available in Wikipedia.|