Intraoperative Neuromonitoring in Spine Surgery: What the World's Largest Global Survey of 529 Surgeons Reveals : Dr Krishna Kumar R

Intraoperative neuromonitoring (IONM) is a real-time nerve-monitoring technology used during spine surgery to detect early warning signs of spinal cord or nerve injury before they become permanent. A 2026 global survey of 529 spine surgeons across five continents — published in the Global Spine Journal — found that most surgeons hold a positive view of IONM and use it consistently for high-risk, spinal cord–level surgery, but nearly 1 in 10 surgeons worldwide have no access to it at all, and economic and logistical barriers remain the biggest obstacles to wider adoption.

Why This Study Matters

For decades, intraoperative neuromonitoring has been recognized as valuable in high-risk spine surgery, but until now, there has been little global data on how consistently it's actually available, who interprets the readings, and how surgeons respond when something goes wrong during a procedure.

To close that gap, the AO Spine Knowledge Forum Deformity conducted a cross-sectional global survey of AO Spine members, gathering responses from 529 spine surgeons across North America, Latin America, Europe & Southern Africa, the Middle East & North Africa, and Asia-Pacific — making it one of the largest and most geographically diverse IONM surveys ever conducted. The study was co-chaired by Dr. Krishna Kumar R, Director of the Institute of Spine and Scoliosis Surgery at VPS Lakeshore Hospital, Kochi, and Dr. Sameh Abolfotouh, and was published in the Global Spine Journal in 2026.

What Is Intraoperative Neuromonitoring (IONM)?

IONM is a set of techniques used to continuously track the function of the spinal cord and nerve roots while a patient is under general anesthesia during spine surgery. Because an anesthetized patient cannot report numbness, weakness, or pain, IONM acts as an early-warning system for the surgical team. Common modalities include:

Somatosensory Evoked Potentials (SSEP) — tracks the sensory pathway from limbs to brain

Motor Evoked Potentials (MEP) — tracks the motor pathway from brain to muscles

Electromyography (EMG) — detects irritation or injury to nerve roots in real time

Key Findings From the Global Survey

55.5% of surgeons have consistent, always-available access to IONM; 35.7% have only occasional access; 8.8% have no access at all

59.5% of practices rely on an external neuromonitoring service, while 40.5% use an in-house team

Neuromonitoring technicians interpret intraoperative data in 63.6% of cases; surgeons interpret it themselves in only 26.1% of cases

97.7% of surgeons use IONM for spinal cord–level surgery, compared with 77.2% for procedures below the conus — showing selective, risk-based use rather than blanket application

When facing an unexpected loss of signal, 76.3% of surgeons use a standardized checklist, while 17.7% perform a wake-up test and 9.1% abort the surgery immediately

Economic constraints (38.2%), logistical challenges (27.4%), and lack of trained personnel (25.6%) are the leading barriers to broader IONM use

91.2% of surgeons agree IONM provides medicolegal protection; 87.8% say it offers intraoperative reassurance; 80% believe it improves patient outcomes

Overall, 50.5% of surgeons hold a positive attitude toward IONM, 44.1% are neutral, and only 5.4% hold a negative attitude

Geographic region, surgical specialty, and access to IONM were independently linked to a more positive attitude — orthopedic surgeons and surgeons practicing outside North America showed significantly higher odds of favorable views.

The Global Access Gap

Perhaps the most striking finding is the access gap itself. While a slim majority of surgeons can rely on IONM being available for every case that needs it, more than 1 in 3 surgeons only have occasional access — and roughly 1 in 11 have none. This isn't a training or awareness problem; it's an infrastructure and reimbursement problem, driven by the cost of neuromonitoring equipment, the global shortage of trained neurophysiologists and neuromonitoring technologists, and the logistics of coordinating outside providers, particularly in low- and middle-income regions.

Risk-Stratified, Not Routine, Use

The survey found that surgeons are not using IONM indiscriminately. Use is nearly universal (97.7%) for spinal cord–level surgery, where the consequences of missed injury are most severe, but drops to 77.2% for lower-risk procedures below the conus. This gap reflects a deliberate, indication-driven approach — surgeons reserve neuromonitoring resources for the cases where neurological risk is highest, rather than applying it as a blanket standard across every operation.

Who Actually Reads the Signals?

A detail with real clinical relevance: in nearly two-thirds of cases (63.6%), intraoperative data is interpreted by a neuromonitoring technician rather than the operating surgeon. Only about a quarter of surgeons interpret the signals themselves. This reflects the multidisciplinary reality of modern IONM — but it also underscores why standardized communication protocols and checklists between the neuromonitoring team and the surgical team matter so much when an alert occurs.

Why Attitudes Differ by Region and Specialty

Multivariate analysis found that orthopedic surgeons were significantly more likely than neurosurgeons to hold a positive attitude toward IONM (OR = 1.83), and surgeons in Asia-Pacific, Latin America, Europe & Southern Africa, and the Middle East & North Africa all showed higher odds of positive attitudes than those in North America. Surgeons with greater access to IONM were also more likely to view it favorably — suggesting that familiarity and routine use build confidence in the technology over time, and that closing the access gap may itself improve global attitudes toward IONM.

What This Means for Patients

If you're facing spine surgery — particularly for a high-risk condition such as spinal deformity, tumor, or trauma — this research suggests a few questions worth raising with your surgical team:

Is intraoperative neuromonitoring available for my procedure, and is it used consistently or only occasionally at this hospital?

Is the neuromonitoring team in-house, or provided by an outside company?

Who interprets the signals during my surgery, and how does the team communicate an alert to my surgeon?

What is the standard response if an unexpected signal change occurs during my operation?

Frequently Asked Questions

What percentage of spine surgeons have access to intraoperative neuromonitoring?

A 2026 global survey of 529 spine surgeons found that 55.5% have consistent access to IONM, 35.7% have only occasional access, and 8.8% have no access at all.

Who interprets intraoperative neuromonitoring data during spine surgery?

According to the same global survey, neuromonitoring technicians interpret the data in 63.6% of cases, while the operating surgeon personally interprets it in only about 26% of cases.

Is intraoperative neuromonitoring used for all spine surgeries?

No. The global survey found IONM is used in 97.7% of spinal cord–level procedures but only 77.2% of procedures performed below the conus, reflecting a risk-stratified, selective approach rather than routine use in every case.

What are the biggest barriers to using intraoperative neuromonitoring worldwide?

The leading barriers identified in the 2026 global survey were economic constraints (38.2%), logistical challenges (27.4%), and a shortage of trained neurophysiologists or neuromonitoring technologists (25.6%).

Do spine surgeons believe intraoperative neuromonitoring is worth using?

Yes. The global survey found that 91.2% of surgeons believe IONM provides medicolegal protection, 87.8% say it offers intraoperative reassurance, and 80% believe it improves patient outcomes. Overall, just over half of surgeons (50.5%) hold a strongly positive attitude, with most of the remainder neutral rather than negative.

What do surgeons do if intraoperative neuromonitoring signals are unexpectedly lost during surgery?

Most surgeons (76.3%) use a standardized checklist to guide their response. Smaller proportions perform a wake-up test (17.7%) or abort the surgery immediately (9.1%), depending on the clinical situation.

About This Research

This analysis is based on: Abolfotouh S, Alnouri M, Lewis S, Kumar K, Abolfotouh MA. A Global Survey on Intra-operative Neuromonitoring (IONM) Practices, Attitudes Towards Its Use, and Barriers Among Spine Surgeons. Global Spine Journal, 2026. DOI: 10.1177/21925682261465345. The study was organized and funded by AO Spine through the AO Spine Knowledge Forum Deformity. 

Dr. Krishna Kumar R, Director of the Institute of Spine and Scoliosis Surgery at VPS Lakeshore Hospital, Kochi, conceived the project and spear headed this research and co-chaired this global research initiative.

This article is for informational purposes and does not replace a consultation with a qualified spine surgeon. If you have questions about neuromonitoring during a planned spine surgery, discuss them directly with your surgical team.

If you are a parent, educator, or someone looking to understand spinal wellness, I highly encourage you to read it.

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Consultations & Community Outreach

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Dr Krishna Kumar R 

Director , 

Institute of Spine and Scoliosis Surgery, 

VPS Lakeshore Hospital, Kochi, Kerala.

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