Intraoperative Monitoring for Spine Surgery in LMICs: Applications, Outcomes, and Access Disparities.

Intraoperative neuromonitoring (IONM) has become an essential tool in modern spine surgery to protect neural structures and minimize the risk of neurological complications. Various IONM techniques, such as motor evoked potentials, electromyography, transcranial motor stimulation, and somatosensory evoked potentials, have been developed to allow surgeons to monitor spinal cord and nerve function in real time and make critical decisions that improve surgical outcomes and reduce neurological deficits. IONM has been effective in improving surgical precision and patient safety in low- and middle-income countries, where spine surgery for degenerative conditions, spinal cord injuries, tumors, and deformities is further complicated by limited healthcare resources. Multimodal IONM is particularly useful in these regions to reduce postoperative neurological deficits and reduce costs by avoiding the need for corrective surgery and extensive rehabilitation. However, there are challenges, including infrastructure and workforce deficiencies, economic constraints, lack of standardized guidelines, and variability of IONM that limit wider implementation. IONM also does not eliminate intraoperative complications, where false positives, false negatives, and signal interpretation problems remain risks. However, the integration of IONM into high-risk spine surgery is a promising strategy to improve outcomes, particularly in resource-limited settings.