A 14-year-old girl with severe idiopathic scoliosis presented for posterior spinal fusion and instrumentation with neurophysiological monitoring (NPM). On the morning of surgery, she received anxiolytic premedication and was brought to the operating room. Induction of anesthesia, tracheal intubation, and the placement of intravascular catheters and NPM leads proceeded smoothly. Standard medications for the case (eg, total intravenous anesthesia infusions, antibiotic prophylaxis, and antifibrinolytic therapy) were administered.

The surgical procedure commenced uneventfully. Approximately two hours into the procedure, the neurophysiologist noted a decrease in NPM signals during placement of surgical screws and voiced his concerns to the rest of the intraoperative team (surgery, anesthesia, and nursing). The team sprang into action to ameliorate the risk of spinal cord ischemia that NPM signal decrements can portend. After the anesthesia team checked their medication infusions and measured the patient’s hemoglobin level and acid-base status, they administered colloid, blood products, and vasoactive medications to improve spinal cord perfusion. Meanwhile, the surgical team deftly removed the recently placed surgical screws and scrutinized the operative site to verify that no inadvertent surgical trauma had occurred. The nursing staff facilitated each step of both anesthesia’s and surgery’s troubleshooting processes with efficiency and poise. The intraoperative team maintained effective, professional communication throughout the incident.

The neurophysiologist reported shortly afterward that NPM signals had improved, and intraoperative radiographic imaging showed no evidence of spinal cord impingement. The attending surgeon and anesthesiologist decided to postpone the remainder of the procedure. Surgical closure and anesthesia emergence and extubation occurred without incident, and the patient was taken to the intensive care unit where she experienced a full recovery with no neurological sequelae.


Intraoperative NPM is used to reduce the risk of unintended injury to the spinal cord during spinal fusion and instrumentation procedures. A decrease in NPM signals warrants immediate investigation and appropriate treatment of potential causes, such as certain anesthetic medications, patient factors (eg, hypotension, hypoxemia, hypothermia, and anemia), and surgical trauma. NPM is performed routinely during CHOP spinal fusion procedures to warn of impending spinal cord injury.

In this case, the intraoperative team used superb clinical acumen and teamwork during a crisis situation to avert a potentially devastating patient outcome. Patient-centered care principles, mutual professional respect, and dedication to constant clinical improvement are ingrained within CHOP’s nurses, anesthesiologists, and orthopedic surgeons, enabling them to skillfully manage any challenging situations that arise.