“EEG for awake brain surgery” - The Dichotomy of IONM Services

In my final year of University, I completed a summer internship with a visual neuroscience research group. I was never a strong student in the classical sense, but I had a propensity for data collection using EEG and MEG, and integrated well with the researchers. Working for this team ignited my passion for electrophysiology. Prior to my final year and internship, I had no direction. My plan was to join the military and hope for the best. From the point where I stand today, the path I took to get here started with a response from a researcher, to a question I had about former graduates of the program.

“I know one of the former honours students now works for a company that performs EEG for awake brain surgeries around the country”

“EEG for awake brain surgeries”, My aerodynamically smooth brained cortex rapidly exploded with ambition and determination and targeted me towards the field of intraoperative neurophysiology. Of course, I did not just simply walk into the OR and start doing “EEG for awake brain surgery”, but it involved extensive training and experience in other monitoring techniques in spinal procedures. The path I took from summer research intern to performing cortico-subcortical motor mapping, was not conventional, nor expected, and hopefully will be referred to as the pre-standardised era, as hopefully more formal pathways to the field appear and become standardised practice.

Today, Intraoperative Neurophysiology in Australia is at a crossroads. As it is in the US and in Europe, IONM can be outsourced to hospitals or be facilitated by an in-house neurophysiology department. The case for an in-house model, with scientists imbedded in the neurology/neurophysiology department the most idealistic. Having an IONM service within the hospital provides access to scientists with close relationship with neurologists, access to visit patients pre-and postoperative follow up, and patient data for long term data collection and retention. This capability is simply not available to outsources IONM providers. Ultimately, the justification for hospitals not having an in-house IONM service, provides insight into the state of education, accreditation, and logistics within the IONM Industry.

Outside looking in, it seems anyone with a science degree can slip into a pair of scrubs, run high current electricity through a patient’s brain, and provide information that may alter decisions made during surgery. This is far from the case, but there is a valid point to argue, that there is little to no benchmark certification a scientist can achieve that surgeons can be sure the monitoring being performed is of the highest standards.

This viewpoint is backed by a 2017 independent review of “technologies in neurophysiology and operating theatres” [Finnigan, 2017] that identified the lack of certification process in IONM in Australia, and a high likelihood that there would be an increase in demand for skilled scientists to support the field. With the lack of certifications or accreditation, it is not to say that the current cohort of neurophysiology scientists in IONM are unqualified, but rather introduce a vast variability of backgrounds, and experience, into a field with an extremely steep learning curve with no common foundation.

But how does this explain why hospital departments don’t provide IONM on a regular basis? External providers of IONM, the private companies, provide an instant fix for the solution. Hospitals can contract out a private company that will attend procedures with a trained neurophysiology scientist and all equipment provided for a relatively low cost per case. This approach also allows for continuity of service and familiarity with surgeons across hospital networks.

In-house departments have several barriers to providing their own service. Firstly, it may not be economically viable to a hospital if the number of cases that require IONM, don’t justify the need or cost for a dedicated scientist and or purchase of IONM equipment. For some hospitals with a neurology/neurophysiology department, these scientists also work in diagnostic neurophysiology, performing EEG, Nerve Conduction Studies, Visual Evoked Potentials, on top of numerous other duties. However, in the instance, a procedure that might be emergent, booked last minute, or exceed department capacity, may leave the hospital without resources to provide IONM and require the need of outsourced support.

For hospitals that have a neurophysiology department, administrators may find themselves in uncharted waters when investigating the business case of IONM. With hospital administrators that are incentivised to cut unnecessary spending, the purchasing of IONM equipment (in some cases exceeding $100,000) or the hiring of new staff (or stretching thin the current workforce), in-house IONM services may be low on the agenda of places to utilise their budget. The issue is further compacted, when no official Australian guidelines exist for building a service. At the end of the investigation, the short-term benefits of in-house may not outweigh the status quo. It seems that for the foreseeable future, the dichotomy of in-house/outsourced models of IONM will remain.

Given the diverse backgrounds, ultimately the skills required to perform IONM in Australia are delivered via two streams. Firstly, the independent/often outsourced providers of IONM (disclaimer: of which is my current responsibility as a clinical educator). Secondly, via tertiary institutions offering units of study within the field, notably the University of Sydney (Master of Science in Medicine (Clinical Neurophysiology)).

Independent providers of IONM education provide a strong offering of boundless applied experience, with on-site learning during surgery, alongside a theoretical education process. This, however, can vary widely depending on the experience of the provider, and the resources available to dedicate to an education program. Tertiary offerings are grounded in exceptional theoretical and academic standing; however, often lack the applied experience required to take the step into the operating theatre. For the graduate, unless sponsored, it also comes at a costly expense to undertake the additional study to hope to leverage a position with a department or company. This is a pathway where one can achieve the same role in IONM as a peer who may enter the role directly through a private company.

Regardless of the model of where a scientist is trained, or what background and qualifications one possesses, my experience is that the scientists who excel in IONM have one thing in common: passion, and a tenacity to go and learn, and build their own skills, rather than wait for education to be inherited down. Without the benchmark standards of a certification, how can one be sure the scientist in the operating room will be the one setting the clinical expectations, or the one trying to meet them?

Granted the variability of various entry pathways into IONM, it seems appropriate now that an Australian certification body create and oversee the process and unify the clinical standards that are required to “run electricity through the brains of patients”. Regardless of what is the most favourable educational model for Australia to follow in IONM, it is best promoted by the hands of local professional societies such as NSSA, INSA, ANSA, as well as the ASNM and ISIN, in the pursuance of best clinical practice, research, and collaboration. Ultimately IONM, in-house or out-sourced, is much more than just “EEG for awake brain surgeries”.

Finnigan S. New and emerging technologies in neurophysiology and operating theatres: an Evidence Check rapid review brokered by the Sax Institute (www.saxinstitute.org.au) for the NSW Ministry of Health, 2017

Written by Thomas Verhellen

Clinical Educator, IONM Pty Ltd