Foundations for evidence-based intraoperative neurophysiological monitoring.
In this review, we recommend means to enhance the evidence-base for intraoperative neurophysiological monitoring (IONM). We address two preliminary issues: (1) whether IONM should be evaluated as a diagnostic test or an intervention, and (2) the state of the evidence for IONM (as presented in systematic reviews, for example). Three reasons may be suggested to evaluate at least some IONM applications as interventions (or as part of an "interventional cascade"). First, practical barriers limit our ability to measure IONM diagnostic accuracy. Second, IONM results are designed to be correlated with interventions during surgery. Third, IONM should improve patient outcomes when IONM-directed intervention alters the course of surgery. Observational evidence for IONM is growing yet more is required to understand the conditions under which IONM, in its variety of settings, can benefit patients. A multi-center observational cohort study would represent an important initial compromise between the pragmatic difficulties with conducting controlled trials in IONM and the Evidence-Based Medicine (EBM) view that large scale randomized trials are required. Such a cohort study would improve the evidence base and (if justified) provide the rationale for controlled trials.
Centre for Evidence-Based Medicine, Department of Primary Care Health Sciences, New Radcliffe House, University of Oxford, Oxford OX2 6GG, United Kingdom.
Jeremy
J
Howick
Neurological Monitoring Associates, LLC, 333 West Brown Deer Road, MS #240, Milwaukee, WI 53217-4925, USA.
Bernard Allan
BA
Cohen
Nuffield Department of Surgical Science, Level 6, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
Peter
P
McCulloch
University of Washington, Department Family Medicine, Seattle, WA 98195, USA.
Matthew
M
Thompson
Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN 55407, USA.
Stanley A
SA
Skinner
D002986:Clinical Trials as Topic; D004569:Electroencephalography; D019317:Evidence-Based Medicine / Q000379:methods*; D005071:Evoked Potentials; D006801:Humans; D007432:Intraoperative Period; D009493:Neurosurgery / Q000379:methods*
Controlled trial; Cost effectiveness; Diagnostic test analysis; EBM; Evidence-Based Medicine; IONM; Intraoperative neurophysiological monitoring; Rate ratio