Best Practice Guidelines for the Execution of Intraoperative Neuromonitoring in Spine Deformity Surgery

To develop expert consensus-based guidelines for the execution of intraoperative neuromonitoring (IONM) in routine adolescent idiopathic scoliosis (AIS) and high-risk spinal deformity cases, with the goal to reduce variability in monitoring practices, optimize patient safety and care, and provide a clear framework for operative teams to reference. A modified Delphi process was used to establish expert consensus on best practices for IONM execution. Three consecutive rounds, each including an online survey and a virtual meeting, were conducted among 16 multidisciplinary experts (pediatric and adult orthopedic and neurosurgical spine surgeons, anesthesiologists, neurologists, and neurophysiologists), followed by a fourth online survey to finalize consensus. An 80% agreement threshold for proposed consensus items was set throughout the process. Items that did not reach consensus were refined based on feedback and redistributed in subsequent rounds. Items that met consensus across all the rounds were incorporated into the final best practice guidelines. Across the three rounds, 14 (87.5%), 13 (81.6%), and 14 (87.5%) experts completed the questionnaires and 12 (75.0%), 11 (68.8%), and 13 (81.6%) experts attended the virtual meetings. All 16 (100%) experts completed the final survey. The expert panel reached consensus on 27 items in the AIS cohort and 25 items in the high-risk cohort; final consensus items were organized into IONM Timeline Checklists for the AIS and high-risk cohorts. Multidisciplinary expert consensus-based guidelines for IONM practices were successfully established intended to standardize neuromonitoring practices, reduce variability in care, and facilitate efforts to improve neurologic safety for AIS and high-risk patients undergoing spinal deformity surgery.