Improved preservation of hearing and facial nerve function in vestibular schwannoma surgery via the retrosigmoid approach in a series of 200 patients

Samii, M.; Gerganov, Venelin M.; Samii, Amir

doi:10.3171/jns.2006.105.4.527

Cited by 358 publications

(283 citation statements)

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“…However, it is our hypothesis that the application of the extracisternal technique may reduce the surgeons' learning curve and improve VS surgical results. The results achieved by our team with overall GTR in 81% and good facial nerve function in 93% of the patients are among the best reported in the recent literature 6,26,27,28,29,30 . We believe that the technical nuance described has a major role on the outcome due to the minimal facial nerve manipulation and mobilization.…”

Section: Discussionsupporting

confidence: 60%

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The extracisternal approach in vestibular schwannoma surgery and facial nerve preservation

Vellutini

Beer‐Furlan

Brock

et al. 2014

Arq. Neuro-Psiquiatr.

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The classical surgical technique for the resection of vestibular schwannomas (VS) has emphasized the microsurgical anatomy of cranial nerves. We believe that the focus on preservation of the arachnoid membrane may serve as a safe guide for tumor removal. Method: The extracisternal approach is described in detail. We reviewed charts from 120 patients treated with this technique between 2006 and 2012. Surgical results were evaluated based on the extension of resection, tumor relapse, and facial nerve function. Results: Overall gross total resection was achieved in 81% of the patients. The overall postoperative facial nerve function House-Brackmann grades I-II at one year was 93%. There was no recurrence in 4.2 years mean follow up. Conclusion: The extracisternal technique differs from other surgical descriptions on the treatment of VS by not requiring the identification of the facial nerve, as long as we preserve the arachnoid envelope in the total circumference of the tumor.Keywords: arachnoid membrane, facial nerve, surgery, vestibular schwannoma, acoustic neurinoma. RESUMOA técnica cirúrgica clássica para ressecção de schwannomas vestibulares enfatiza a anatomia microcirúrgica dos nervos cranianos. Acreditamos que o foco na preservação da membrana aracnóide pode servir como parâmetro seguro para a remoção do tumor. Método: A abordagem extracisternal é descrita em detalhe. Analisamos o prontuário de 120 pacientes tratados com esta técnica entre 2006 e 2012. Os resultados cirúrgicos foram baseados em extensão de ressecção, recorrência tumoral e função do nervo facial. Resultados: Ressecção total foi obtida em 81% dos pacientes. O resultado global da função do nervo facial (House-Brackmann graus I-II) após um ano da cirurgia foi de 93%. Não houve recidiva em um seguimento médio de 4,2 anos. Conclusão: A técnica extracisternal difere de outras descrições cirúrgicas no tratamento de schwannoma vestibular pois não requer a identificação do nervo facial, contanto que o plano de aracnóide seja preservado em toda circunferência do tumor.Palavras-chave: membrana aracnóide, nervo facial, cirurgia, schwannoma vestibular, neurinoma do acústico.Facial nerve injury is a common complication in the treatment of vestibular schwannomas (VS) and its associated facial muscle palsy has a great impact in patients' quality of life 1 . This is the reason why functional preservation of the facial nerve is sought when managing VS with either radiosurgery or microsurgery. Several factors have been correlated with worse facial nerve function outcomes, including older patients, large tumors, and preoperative facial nerve function 2,3,4 . Although careful facial nerve dissection is pursued, anatomical preservation of the facial nerve is not synonymous of normal function 5,6,7 . Intraoperative monitoring of the facial nerve is the key for optimal facial nerve preservation, even though not all patients' clinical courses correlate with their intraoperative electrophysiological result 6,8 . The classical descriptions of the surgical tech...

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Section: Discussionsupporting

confidence: 60%

“…It is known that the results on VS surgery depend more on the individual surgeon's experience than on the advantages or disadvantages of a particular approach 26 . However, it is our hypothesis that the application of the extracisternal technique may reduce the surgeons' learning curve and improve VS surgical results.…”

Section: Discussionmentioning

confidence: 99%

The extracisternal approach in vestibular schwannoma surgery and facial nerve preservation

Vellutini

Beer‐Furlan

Brock

et al. 2014

Arq. Neuro-Psiquiatr.

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“…15,22,40,64,75 The length of contact of the tumor with the nerve has also been suggested as a potential prognostic factor. 18 Samii et al 74 believe that prior surgery or radiosurgery and the presence of an intratumoral cyst are negative predictors of postoperative facial nerve function. Facial nerve function may be best preserved through the retrosigmoid corridor, according to current data.…”

Section: Facial Nerve Functionmentioning

confidence: 99%

Surgery for vestibular schwannomas: a systematic review of complications by approach

Ansari

Terry

Cohen-Gadol

2012

FOC

250

216

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Object Various studies report outcomes of vestibular schwannoma (VS) surgery, but few studies have compared outcomes across the various approaches. The authors conducted a systematic review of the available data on VS surgery, comparing the different approaches and their associated complications. Methods MEDLINE searches were conducted to collect studies that reported information on patients undergoing VS surgery. The authors set inclusion criteria for such studies, including the availability of follow-up data for at least 3 months, inclusion of preoperative and postoperative audiometric data, intraoperative monitoring, and reporting of results using established and standardized metrics. Data were collected on hearing loss, facial nerve dysfunction, persistent postoperative headache, CSF leak, operative mortality, residual tumor, tumor recurrence, cranial nerve (CN) dysfunction involving nerves other than CN VII or VIII, and other neurological complications. The authors reviewed data from 35 studies pertaining to 5064 patients who had undergone VS surgery. Results The analyses for hearing loss and facial nerve dysfunction were stratified into the following tumor categories: intracanalicular (IC), size (extrameatal diameter) < 1.5 cm, size 1.5–3.0 cm, and size > 3.0 cm. The middle cranial fossa approach was found to be superior to the retrosigmoid approach for hearing preservation in patients with tumors < 1.5 cm (hearing loss in 43.6% vs 64.3%, p < 0.001). All other size categories showed no significant difference between middle cranial fossa and retrosigmoid approaches with respect to hearing loss. The retrosigmoid approach was associated with significantly less facial nerve dysfunction in patients with IC tumors than the middle cranial fossa method was; however, neither differed significantly from the translabyrinthine corridor (4%, 16.7%, 0%, respectively, p < 0.001). The middle cranial fossa approach differed significantly from the translabyrinthine approach for patients with tumors < 1.5 cm, whereas neither differed from the retrosigmoid approach (3.3%, 11.5%, and 7.2%, respectively, p = 0.001). The retrosigmoid approach involved less facial nerve dysfunction than the middle cranial fossa or translabyrinthine approaches for tumors 1.5–3.0 cm (6.1%, 17.3%, and 15.8%, respectively; p < 0.001). The retrosigmoid approach was also superior to the translabyrinthine approach for tumors > 3.0 cm (30.2% vs 42.5%, respectively, p < 0.001). Postoperative headache was significantly more likely after the retrosigmoid approach than after the translabyrinthine approach, but neither differed significantly from the middle cranial fossa approach (17.3%, 0%, and 8%, respectively; p < 0.001). The incidence of CSF leak was significantly greater after the retrosigmoid approach than after either the middle cranial fossa or translabyrinthine approaches (10.3%, 5.3%, 7.1%; p = 0.001). The incidences of residual tumor, mortality, major non-CN complications, residual tumor, tumor recurrence, and dysfunction of other cranial nerves were not significantly different across the approaches. Conclusions The middle cranial fossa approach seems safest for hearing preservation in patients with smaller tumors. Based on the data, the retrosigmoid approach seems to be the most versatile corridor for facial nerve preservation for most tumor sizes, but it is associated with a higher risk of postoperative pain and CSF fistula. The translabyrinthine approach is associated with complete hearing loss but may be useful for patients with large tumors and poor preoperative hearing.

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“…The details of the technique have been discussed in detail previously and only the main steps are highlighted here [12,15]. The goal of surgery has always been to achieve Neurophysiological monitoring: continuous electrophysiological monitoring using a commercially available hardware and software (Endeavor CR intraoperative monitor; VIASYS Healthcare, Nicolet Biomedical, Madison, WI) provided feedback regarding the functional integrity of the facial and cochlear nerves [14,15].…”

Section: A C C E P T E D Article In Pressmentioning

confidence: 99%

An electrophysiological study on the safety of the endoscope-assisted microsurgical removal of vestibular schwannomas

Gerganov

Giordano

Herold

et al. 2010

European Journal of Surgical Oncology (EJSO)

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This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. M A N U S C R I P T A C C E P T E D ARTICLE IN PRESS

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Improved preservation of hearing and facial nerve function in vestibular schwannoma surgery via the retrosigmoid approach in a series of 200 patients

Abstract: The goal of VS treatment should be total removal in one stage and preservation of neurological function, as they determine a patient's quality of life. This goal can be safely and successfully achieved using the retrosigmoid approach.

Cited by 358 publications

References 46 publications

The extracisternal approach in vestibular schwannoma surgery and facial nerve preservation

The extracisternal approach in vestibular schwannoma surgery and facial nerve preservation

Surgery for vestibular schwannomas: a systematic review of complications by approach

An electrophysiological study on the safety of the endoscope-assisted microsurgical removal of vestibular schwannomas

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