title: Best Practices in Intraoperative Neuromonitoring in Spine Deformity Surgery: Development of an Intraoperative Checklist to Optimize Response.
abstract: METHODS
  Consensus-based creation of a checklist and guideline.
  
  
  OBJECTIVE
  To develop a consensus-based checklist to guide surgeon responses to intraoperative neuromonitoring (IONM) changes in patients with a stable spine and to develop a consensus-based best practice guideline for IONM practice in the United States.
  
  
  BACKGROUND
  Studies show that checklists enhance surgical team responses to crisis situations and improve patient outcomes. Currently, no widely accepted guidelines exist for the response to IONM changes in spine deformity surgery.
  
  
  METHODS
  After a literature review of risk factors and recommendations for responding to IONM changes, 4 surveys were administered to 21 experienced spine surgeons and 1 neurologist experienced in IONM. Areas of equipoise were identified and the nominal group process was used to determine items to be included in the checklist. The authors reevaluated and modified the checklist at 3 face-to-face meetings over 12 months, including a period of clinical validation using a modified Delphi process. The group was also surveyed on current IONM practices at their institutions. This information and existing IONM position statements were used to create the IONM best practice guideline.
  
  
  RESULTS
  Consensus was reached for the creation of 5 checklist headings containing 26 items to consider in the response to IONM changes. Consensus was reached on 5 statements for inclusion in the best practice guideline; the final guideline promotes a team approach and makes recommendations aimed at decreasing variability in neuromonitoring practices.
  
  
  CONCLUSIONS
  The final products represent the consensus of a group of expert spine surgeons. The checklist includes the most important and high-yield items to consider when responding to IONM changes in patients with a stable spine, whereas the IONM guideline represents the group consensus on items that should be considered best practice among IONM teams with the appropriate resources.
authors.affiliation: Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY 10032, USA.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Vitale
authors.affiliation: Department of Orthopedic Surgery, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA.
authors.forename: David L
authors.initials: DL
authors.lastname: Skaggs
authors.affiliation: Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY 10032, USA.
authors.forename: Gregory I
authors.initials: GI
authors.lastname: Pace
authors.affiliation: Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY 10032, USA.
authors.forename: Margaret L
authors.initials: ML
authors.lastname: Wright
authors.affiliation: Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY 10032, USA. Electronic address: hm2174@columbia.edu.
authors.forename: Hiroko
authors.initials: H
authors.lastname: Matsumoto
authors.affiliation: Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA.
authors.forename: Richard C E
authors.initials: RC
authors.lastname: Anderson
authors.affiliation: Department of Neurosurgery, University of Utah, Salt Lake City, UT 84112, USA.
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Brockmeyer
authors.affiliation: Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA.
authors.forename: John P
authors.initials: JP
authors.lastname: Dormans
authors.affiliation: Department of Orthopedic Surgery, Harvard Medical School, Boston, MA 02115, USA.
authors.forename: John B
authors.initials: JB
authors.lastname: Emans
authors.affiliation: Department of Orthopedic Surgery, University of Colorado, Denver, CO 80202, USA.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Erickson
authors.affiliation: Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA.
authors.forename: John M
authors.initials: JM
authors.lastname: Flynn
authors.affiliation: Department of Orthopedic Surgery, Harvard Medical School, Boston, MA 02115, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Glotzbecker
authors.affiliation: Department of Orthopedic Surgery, Loyola University, Chicago, IL 60660, USA.
authors.forename: Kamal N
authors.initials: KN
authors.lastname: Ibrahim
authors.affiliation: Department of Orthopedic Surgery, Toronto Western Hospital, Toronto, Ontario M5T 2S8, Canada.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Lewis
authors.affiliation: Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO 63130, USA.
authors.forename: Scott J
authors.initials: SJ
authors.lastname: Luhmann
authors.affiliation: Department of Neurology, Columbia University Medical Center, New York, NY 10032, USA.
authors.forename: Anil
authors.initials: A
authors.lastname: Mendiratta
authors.affiliation: Department of Orthopedic Surgery, Texas Scottish Rite Hospital, Dallas, TX 75219, USA.
authors.forename: B Stephens
authors.initials: BS
authors.lastname: Richards
authors.affiliation: Department of Orthopedic Surgery, University of Rochester, Rochester, NY 14627, USA.
authors.forename: James O
authors.initials: JO
authors.lastname: Sanders
authors.affiliation: Department of Orthopedic Surgery, Nemours/AI duPont, Wilmington, DE 19803, USA.
authors.forename: Suken A
authors.initials: SA
authors.lastname: Shah
authors.affiliation: Department of Orthopedic Surgery, University of Utah, Salt Lake City, UT 84112, USA.
authors.forename: John T
authors.initials: JT
authors.lastname: Smith
authors.affiliation: Department of Orthopedic Surgery, Shriners Hospitals for Children, Los Angeles, CA 90020, USA.
authors.forename: Kit M
authors.initials: KM
authors.lastname: Song
authors.affiliation: Department of Orthopedic Surgery, Johns Hopkins Medical Center, Baltimore, MD 21287, USA.
authors.forename: Paul D
authors.initials: PD
authors.lastname: Sponseller
authors.affiliation: Department of Orthopedic Surgery, Texas Scottish Rite Hospital, Dallas, TX 75219, USA.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Sucato
authors.affiliation: Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY 10032, USA.
authors.forename: David P
authors.initials: DP
authors.lastname: Roye
authors.affiliation: Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO 63130, USA.
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Lenke
keywords: Neuromonitoring; Spine deformity surgery; Surgical checklist