A Global Survey on Intra-operative Neuromonitoring (IONM) Practices, Attitudes Towards Its Use, and Barriers Among Spine Surgeons
Sameh Abolfotouh, Mason Alnouri, Stephen Lewis, Krishna Kumar, Mostafa A. AbolfotouhStudy Design
Cross-sectional survey study.
Objectives
To provide a contemporary global overview of intra-operative neuromonitoring (IONM) practices, attitudes, and perceived barriers among spine surgeons.
Methods
A web-based questionnaire was distributed to AO Spine surgeon members worldwide between April and May 2025 to collect data on surgeon demographics, access to and utilization of IONM, models of service delivery, intra-operative responses to neuromonitoring alerts, attitudes toward IONM, and perceived limitations. Attitudes were assessed using 13 Likert-scale statements. Logistic regression analysis was performed to identify factors associated with a positive attitude toward IONM. Significance was set at p<0.05.
Results
A total of 529 spine surgeons responded to the survey. Consistent access to IONM was reported by 55.5% of respondents, occasional access by 35.7%, and no access by 8.8%. External service providers were the most used IONM model (59.5%). Neuromonitoring technicians most frequently interpret intraoperative data (63.6%). In response to unexpected signal loss, most surgeons reported using a standardized checklist (76.3%). Overall attitudes toward IONM were predominantly positive, with most respondents agreeing that IONM improves patient outcomes, provides medicolegal protection, and offers surgeon reassurance. Economic constraints (38.2%), logistical challenges (27.4%), and lack of training (25.6%) were the most reported barriers. Multivariate analysis identified geographic region, specialty, and access to IONM as independent predictors of a positive attitude.
Conclusions
This global survey demonstrates widespread acceptance of IONM among spine surgeons, particularly for high-risk procedures. However, disparities in access and persistent economic and logistical barriers remain, highlighting the need for strategies to improve equitable implementation worldwide.