ArticleJournal of neuro-oncology2026
Subperineural 'onion-peeling' dissection for maximizing extent of resection and facial nerve preservation for onco-functional balance in vestibular schwannoma surgery.
Article in Journal of neuro-oncology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
introductionPlanned subtotal resection (STR) of vestibular schwannomas (VS) followed by stereotactic radiosurgery (SRS) has gained popularity for minimizing facial nerve injury. However, recurrence risk correlates with residual tumor volume, and long-term outcomes remain unknown. The authors report their facial nerve outcomes with planned maximal safe resection using a facial nerve-sparing subperineural "onion-peeling" technique, and compare their outcomes to those of the hybrid STR-SRS approach.
methodsA retrospective study was performed on 146 patients who underwent VS resection by a single surgeon using a subperineural "onion-peeling" technique, leaving a thin layer of perineurium as an anatomic buffer overlying the facial nerve. Tumor size, operative approach, extent of resection (EOR: GTR 100%, NTR 95-99%, STR < 95%), facial nerve outcomes by House-Brackmann (HB) grade, recovery time, recurrence, and postoperative SRS usage were analyzed.
resultsMost tumors were Koos grade III-IV (69.9%), followed by grade I-II (30.2%), removed via retrosigmoid (86.3%) or translabyrinthine (13.7%) approaches. At last follow-up (mean follow-up = 89.8 months), 95.2% of patients achieved HB I-II scores while obtaining an EOR ≥ 95% (GTR/NTR) in 97.3% of patients. There was no significant difference in rates of HB I-II outcomes whether EOR was GTR or NTR (97.8% vs. 92.5%, p = 0.196). HB I-II outcomes were achieved in 100% of Koos I-II and 93.1% of Koos III-IV tumors. There was a trend of decreased GTR and increased NTR with increasing Koos grade I to IV (GTR: 93.75%, 86.2%, 76.9%, 39.5%; NTR: 6.25%, 13.8%, 23.1%, 55.3%, respectively). Postoperative CSF leak rate was 2.7%. Tumor recurrence (3.4%) was lower with GTR than NTR (1.1% vs. 7.5%, p = 0.0646).
conclusionThe subperineural "onion-peeling" dissection technique provides a safe, nerve-sparing approach for maximal VS resection while preserving facial nerve function thus achieving excellent onco-functional outcomes. Compared to historical hybrid STR-SRS data, our approach demonstrated favorable facial nerve outcomes with higher EOR, lower tumor recurrence, and less radiation usage.
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