Intraoperative Neuromonitoring: Fundamentals, Possibilities, Limitations

Intraoperative neurophysiological monitoring (IONM) has gained increasing interest during the past decades and is now an integral part of various surgical disciplines, especially in neurosurgery, but also in otolaryngology, orthopedics, vascular surgery and general surgery. With expanding applications and evolving techniques, the monitoring team is faced with increasingly complex tasks and responsibilities. Despite its importance and significance in modern surgical medicine and the expectations associated with it, IONM is still not a regular part of the training program of medical professionals. Although knowledge on monitoring is imparted in basic courses offered by a few professional societies, systematic training of medical and non-medical staff according to a standardized curriculum is still lacking.This book aims to contribute to closing this gap. It provides a practical guide to help medical, nursing, and technical personnel get familiar with intraoperative neuromonitoring. The basic tenor is to combine theoretical and practical knowledge and thus to systematically convey essential skills about fundamentals, possibilities, but also limitations of IONM to a broad circle of readers. In order to achieve this goal, the text has been reduced to the absolutely necessary length in favor of numerous illustrations and tables.

After an introduction to the tasks, the significance, and the historical development of IONM, the anatomical, physiological and physical basics are presented. This is followed by a presentation of various modalities as well as stimulation and recording techniques. The intraoperative part begins with some information on the organizational processes in the operating room, the presentation of safety aspects, and a description of the influences of anesthesia on monitoring, including the special aspects of awake surgery. This is followed by some basic remarks on the interpretation of monitoring results and a rough overview of the application fields of IONM in various disciplines including representative case examples. The manual concludes with an evaluation of the efficiency of monitoring and practical recommendations for the detection and elimination of intraoperative sources of error. Self-tests in individual chapters are intended to give readers the opportunity to determine their level of knowledge.

Josef Zentner received his neurosurgical training at the Department of Neurosurgery, University of Freiburg, Germany. He completed his PhD in neurophysiology with studies on intraoperative motor evoked potential monitoring at the Department of Neurosurgery in Tübingen. A fellowship in the USA and Canada acquainted him with epilepsy surgery. As the vice chairman of the Department of Neurosurgery in Bonn he took over the surgical part of the epilepsy surgical program in 1990 and was appointed to a professorship (C3) 1994. In 1997 he received  full professorship (C4) and chair of the Department of Neurosurgery, University of Freiburg. In collaboration with the epilepsy center Kehl/Kork,  Dr. Zentner established a grade IV center for epilepsy surgery in Freiburg. Neurophysiology and epilepsy surgery continued to be the main areas of his interest. In 2003 Dr. Zentner was appointed president of the German chapter of the International League Against Epilepsy (ILAE). In addition, he served as dean of the Medical Faculty of the University of Freiburg from 2003 to 2005. Dr. Zentner was active on several editorial boards and published many articles on various aspects of neurophysiology and epilepsy surgery. Among other research foundations, his scientific work was supported by the DFG. Dr. Zentner retired in 2018. Over the past  years, he summarized his experience with epilepsy surgery in his 2020 monograph, Surgical Treatment of Epilepsies - Diagnosis, Surgical Strategies, Results. 

Dr. David MacDonald trained in medicine and neurology at Dalhousie University, Halifax, Nova Scotia, Canada. He then studied electroencephalography (EEG) and evoked potentials (EPs) at the MAYO Clinic, Rochester, Minnesota, United States. He was Director of the intraoperative neurophysiologic monitoring (IONM) program, EEG/EP laboratory, and seizure investigation unit at the University of British Columbia in Vancouver, Canada from 1991 to 1999, and became an assistant clinical professor of neurology. Then he headed the Section of Neurophysiology in the Department of Neurosciences at the King Faisal Specialist Hospital & Research Center in Riyadh, Saudi Arabia from 2000 to 2012, and remained as consultant intraoperative neurophysiologist, neurologist, and epileptologist until 2020. In 2021, he became Scientific Director for Arkana Forum in Emmendingen, Germany to focus on IONM education and training. Dr. MacDonald is also a past President of the International Society of Intraoperative Neurophysiology (ISIN), and its current Scientific Committee Co-Chair. His main fields of expertise include IONM, EEG, EPs, epilepsy, teaching, research, and guideline development. He is a frequently requested speaker, and has published many articles and chapters, including guidelines for the ISIN, the American Society of Clinical Neurophysiology, and the American Society of Neurophysiologic monitoring. In addition, he is Associate Editor of Clinical Neurophysiology, the official journal of the International Federation of Neurophysiology, as well as an Editorial Board member for the Journal of Clinical Neurophysiology and the Journal of Clinical Monitoring and Computing.
Celine Wegner received her Master of Science degree in the field of Biomedical Engineering from  Furtwangen University in 2014. From 2014 till 2020 she worked in the Research Department of inomed Medizintechnik focusing her work on new methods of nerve stimulation and neurophysiologic recording. In 2016 she joined ARKANA Forum as scientific support, responsible for the content support in the development of teaching material and of educational events. 2020 to 2021 she was the managing director of iNCU, a company with 8 employees providing intraoperative neuromonitoring as a service to hospitals. Here the focus of her work was on development of the company as well as personnel, especially training of new employees. In 2021 she rejoined ARKANA Forum as a project manager for medical education and is dedicating her work here on further developing education in the field on intraoperative neurophysiologic monitoring.