I. Intraoperative Neuromonitoring Anesthesia techniques influence the effectiveness of spinal cord monitoring. There are 3 main modalities of IOM currently used: the Stagnara wake-up test, somatosensoryevokedpotentials (SSEP), and motor evoked potentials (MEP). During the wake-up test, anesthetics, opioids were discontinued. Neuromuscular blocking agents, patients were awakened and asked to move their arms and legs. After there are no abnormalities, the patient is anesthetized again to complete the procedure. The wake-up test is applied only at specific moments of need to assess spinal cord function and not continuously during the procedure.After MEP loss and after excluding hypotension, hypothermia, hypercapnia, and anesthetic interference, we perform the wake-up test in patients with severe deformities. False-negative results sometimes occur. Because techniques such as transcranial MEP and SSEP are still not available in most areas, it is recommended that the surgical team be very familiar with wake testing. II.SURGICAL TECHNIQUES There are a variety of surgical approaches to treating pediatric spinal deformities. They include posterior spinal fusion (with or without internal fixation), anterior spinal fusion (with or without internal fixation), and combined anterior and posterior surgery (with or without internal fixation). Because of the powerful orthopedic effect of pedicle screws, their use has reduced the need for combined anterior and posterior surgery, especially in osteotomies. C-arm machines are rarely available in most operating rooms in developing countries. Therefore, the surgeon must master the technique of freehand screw placement. In order to safely implant the screws, a careful preoperative evaluation and examination should be performed to familiarize the pedicle dimensions and anatomy. When screw implantation is difficult using this method, a Penfield dissector can be used to perform a microdissection to palpate the inner wall of the pedicle for screw implantation.