Should decompressive surgery for myelopathy be abandoned if positioning causes loss of neuromonitoring signals?

Background and Objectives Intraoperative neuromonitoring (IOM) has become a safeguarding necessity in the prevention of neurological injury during spinal surgery. Early loss of IOM signals during myelopathy decompression surgery after positioning poses a dilemma on whether to proceed with surgery aiming at saving the spinal cord, versus abandonment for prevention of further loss. Thus, it has become ethically and legally important to establish best practices in this regard. Materials and Methods The Delphi method was adopted, sending a survey to spine consultants in the United Kingdom. This was sent to members of the British Association of Spine Surgeons with a binary yes/no response to foregoing surgery if the IOM signal is lost. An optional question was also added on their justification. A systematic literature review was simultaneously conducted. Results Thirty-two opinions were received; 72% recommended proceeding with surgery. Their justification was the necessity to decompress the already known compromised cord. Some surgeons did not feel that IOM was needed in these cases. The other 28% suggested reversal of positioning while optimising factors that could affect monitoring, thus avoiding adding further harm. There was one important consideration that was consistently echoed in the responses, which was the need to discuss this scenario with the patients before surgery. Conclusion IOM is optional in decompressive surgery for degenerative myelopathy. Loss of IOM signal is a relative contraindication to the continuation of surgery. Proper consent of the patients preoperatively should include exploring the loss of IOM scenario after positioning and prior to skin incision.