Intraoperative neuromonitoring and anesthesia considerations in peripheral nerve surgeries

Background: Peripheral nerve surgery has evolved considerably with advances in microsurgical techniques and intraoperative neurophysiological monitoring aimed at preserving neural function and improving postoperative outcomes. Intraoperative neuromonitoring (IONM) provides real-time assessment of neural integrity, facilitates identification of functional neural tissue, and may reduce the risk of iatrogenic nerve injury. Commonly used modalities include free-running and triggered electromyography (EMG), somatosensory evoked potentials, motor evoked potentials, and nerve action potential (NAP) recordings. These techniques provide complementary information regarding neural function and are increasingly incorporated into complex peripheral nerve procedures. Objective: This narrative review aims to review the current principles and clinical applications of IONM in peripheral nerve surgery, with particular emphasis on the interaction between anesthetic management and neurophysiological monitoring. Discussion: This narrative review summarizes the principles and clinical applications of IONM in peripheral nerve surgery, with particular emphasis on anesthetic considerations. It examines the effects of anesthetic agents and techniques on commonly used monitoring modalities, strategies for optimizing intraoperative monitoring conditions, and approaches to troubleshooting changes in neurophysiological signals. Conclusion: A comprehensive understanding of the interaction between anesthesia, surgery, and neurophysiological monitoring is essential for optimizing intraoperative decision-making, minimizing neurological complications, and supporting functional recovery following peripheral nerve procedures.