Major neurologic injury is a feared complication in central and spinal neurosurgery, with devastating impacts on patients and healthcare. Intraoperative neurophysiologic monitoring (IONM) detects impending injury by assessing the integrity of the nervous system through evoked potentials (EPs), allowing for potential corrective action before irreversible damage occurs. The anesthetic goals during IONM include adequate anesthesia depth, hemodynamic stability, pain management, optimization of somatosensory and transcranial motor evoked potentials (SSEP and TcMEP), and minimization of postoperative cognitive dysfunction. Subanesthetic doses of ketamine, delivered as an anesthetic adjuvant, enhance EP amplitude, maintain EP latency, reduce other anesthetic agents use, and provide hemodynamic stability and analgesia, improving recovery. Disadvantages include challenges in assessing anesthetic depth, poor performance in wake-up tests, and possibly unwanted psychoactive effects postoperatively. While general recommendations regarding ketamine use remain unclear, it is clearly advantageous when reliable TcMEP recordings are crucial for patient safety.