Real-World Surgeon Perspectives on Intraoperative Neuromonitoring in Spine Surgery: Analysis of Practice Patterns and Evidence Gaps

Study Design: Cross-sectional international surgeon survey with Rasch analysis. Objective: To assess surgeon perspectives on intraoperative neuromonitoring (IONM) in spine surgery and identify areas of consensus and controversy in real-world adoption. Materials and Methods: A 93-item PICO-based survey was completed by 93 surgeons (53% orthopedic, 43% neurosurgery) across 22 countries. Responses underwent Rasch modeling to assess consensus, variability, and item difficulty. Person–item maps and Wright plots were used to visualize agreement. Results: Real-world adoption is shaped by operator dependency, cost, and administrative barriers. Rasch fit statistics confirmed stability of a strong consensus among surgeons that IONM reduces neurological complications and is essential in high-risk procedures (posterior cervical and complex lumbar). In contrast, misfit, divergence and polarization were found concerning the routine use in low-risk degenerative and anterior cervical cases, as well as on cost justification. Conclusions: Global spine surgeons endorse IONM as a safety measure in high-risk surgery but remain divided on its role in routine, low-risk procedures. These findings underscore the importance of risk-stratified implementation and highlight the need for evidence-based protocols to bridge the gap between literature-supported efficacy and real-world practice.