Vestibular schwannoma microsurgery in the era of multimodal treatment: advances in technique and patient selection.

backgroundThe management of vestibular schwannoma (VS) has traditionally prioritized gross total resection to achieve high tumor control, often at the cost of cranial nerve injuries and quality of life impairment. However, advances in surgical approaches and intraoperative technologies, coupled with active surveillance and/or adjuvant treatment, have shifted the management paradigm towards prioritizing patient-centered outcomes, which are as critical as oncological control. CONTENT: The authors reviewed the technical advances driving this paradigm shift, including endoscopic assistance in the different microsurgical approaches (retrosigmoid, translabyrinthine, and middle cranial fossa approaches) of VS resection and advanced neuromonitoring (facial nerve electromyography and cochlear/auditory evoked potentials monitoring) and neuronavigation techniques. These innovations have improved rates of total resection and enhanced the safety of microsurgical resection in preserving cranial nerve function, particularly for large symptomatic tumors. We also highlight how tumor size, hearing status, preservation of facial nerve function, and quality of life considerations guide management decisions.

conclusionThe advancements in VS surgery management necessitate a balance between durable tumor control on the one hand and functional and quality of life preservation on the other. These nuances have placed microsurgery as the primary management modality for large tumors threatening neurological function, for definitive treatment in young patients where long-term control is paramount, for hearing preservation in small-medium sized tumors, for debilitating vestibular symptoms with large tumors, and for salvage therapy after radiosurgery failure. These advancements should be incorporated in the surgical armamentarium of skull base surgeons.