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Editors' Note: We are publishing all previously posted dialogue about intraoperative spinal monitoring. Evidence-based medicine (EBM) is a laudable goal, but it is clear that well-intentioned authorities will have strongly held opinions based on their review of the same evidence. The concluding letter by Gronseth, arguably our specialty's leading figure in EBM, does not “give the answer” but does suggest a way forward. Robert C. Griggs, MD, and Megan Alcauskas, MD # {#article-title-2}Nuwer et al.1 consolidated the best evidence available on the use of evoked potentials during spinal operations. However, focusing on the value of intraoperative neurophysiological monitoring (IOM) alerts in predicting postoperative motor deficits does not offer new answers to the question “Why use IOM?” The guideline authors agree with the results of a review2 that supported IOM as a predictive diagnostic tool with a high level of evidence. Prediction alone is insufficient to warrant use of IOM especially when actual outcomes will be revealed almost immediately following the surgery. Also, short-term prediction is insufficient to justify the costs of the specialized equipment, technicians, and professional oversight necessary for proper IOM performance. The evidence for IOM to alter outcomes is weak with only one nonrandomized study3 showing a 52% rate of preventing neurologic deficits from acting on IOM alerts. In the absence of randomized controlled trials, outcomes research from large observational datasets may clarify the utility of IOM as cost-effectiveness becomes a greater factor in medical decision-making.4# Author Response: {#article-title-3}IOM raises warnings early enough to allow for interventions during spinal cord surgery. We believe clinical experience and animal experiments establish unequivocally that IOM warns of spinal cord injury, and interventions reverse impairment and prevent paraplegia. Our assessment1 discussed this rationale and cited literature.The assessment process was constrained narrowly …

neurology

Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Clinical Neurophysiology Society