A cohort study was conducted by researchers after the fact. Anterior Lumbar Interbody Fusion (ALIF) was a surgical procedure that improves lordosis and restores neurological height in individuals with the degenerative illness of the lower lumbar spine. Iatrogenic nerve root injury was one of ALIF’s risks. This injury might be avoidable with IONM. A retrospective cohort study of 111 consecutive patients who had ALIF at a tertiary care academic center by 6 spine surgeons was conducted. Investigators wanted to see if there was a link between IONM and postoperative weakness and whether there were any factors that made our center more likely to use IONM. The median age of the 111 patients was 62 [interquartile range (IQR): 53–69 years]. Neuromonitoring was employed in 67 individuals (60.3%) and not in 44. IONM alterations were seen in 7 neuromonitoring patients during surgery. Intraoperative changes were made in 3 of these patients’ operations to prevent iatrogenic brain damage. The IONM group had more complicated procedures [5 levels (IQR: 3–7) vs. 2 levels (IQR: 2–5), P=0.001] considerably. The rates of new or exacerbated postoperative weakness were not different (IONM: 20.6%, non-IONM: 20.5%). The study team shows that IONM may be beneficial to ALIF patients. Surgical corrections were made due to intraoperative changes in neuromonitoring data, which likely prevented postoperative neurological impairments. Because IONM protected against postoperative weakness, more sophisticated operations did not result in a higher rate of liability.