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Bite injuries associated with transcranial electric stimulation are an uncommon but disturbing complication of TcMEP monitoring occurring with an incidence of 0.63% (95% confidence interval: 0.52%-0.76%), the most severe of which requiring sutures at an incidence of 0.14% (95% confidence interval: 0.09%-0.21%). Injuries of the tongue occur approximately 4 times as frequently as injuries of the lip. Despite placement of bite blocks, shifting of the bite block during stimulation or positioning is a possible cause of failure. High-intensity transcranial stimulation may increase the risk of bite injuries. We suggest consistent use of properly sized and secured bite blocks with periodic inspection to minimize risk of bite injuries. Future study is needed to determine optimal bite block configuration.

Objectives/HypothesisFacial nerve monitoring (FNM) has evolved into a widely used adjunct for many surgical procedures along the course of the facial nerve. Even though majority opinion holds that FNM reduces the incidence of iatrogenic nerve injury, there are few if any studies yielding high‐level evidence and no practice guidelines on which clinicians can rely. Instead, a review of the literature and medicolegal cases reveals significant variations in methodology, training, and clinical indications.Study DesignLiterature review and expert opinion.MethodsGiven the lack of standard references to serve as a resource for FNM, we assembled a multidisciplinary group of experts representing more than a century of combined monitoring experience to synthesize the literature and provide a rational basis to improve the quality of patient care during FNM.ResultsOver the years, two models of monitoring have become well‐established: 1) monitoring by the surgeon using a stand‐alone device that provides auditory feedback of facial electromyography directly to the surgeon, and 2) a team, typically consisting of surgeon, technologist, and interpreting neurophysiologist. Regardless of the setting and the number of people involved, the reliability of monitoring depends on the integration of proper technical performance, accurate interpretation of responses, and their timely application to the surgical procedure. We describe critical steps in the technical set‐up and provide a basis for context‐appropriate interpretation and troubleshooting of recorded signals.ConclusionsWe trust this initial attempt to describe best practices will serve as a basis for improving the quality of patient care while reducing inappropriate variations.Level of Evidence4 Laryngoscope, 131:S1–S42, 2021

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Somatosensory Evoked Potentials (SSEP) are used frequently in spinal instrumentation cases. In this report, we describe electrocardiographic artifacts from SSEP monitoring and offer a new explanation of the etiology.