Month: September 2025

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Awake surgery with direct electrical stimulation mapping and real‑time cognitive monitoring for functionally guided tumor resection

Acta Neurochirurgica (2025) 167:239

Awake surgery with direct electrical stimulation and real-time cognitive monitoring enables maximal safe brain tumor resection by mapping individual functional networks, preserving quality of life and cognitive abilities. This multidisciplinary, patient-centered approach is gold standard for low-grade gliomas and is increasingly applied to other brain tumors.

• Awake surgery with direct electrical stimulation (DES) mapping is the gold standard for low-grade glioma resection and can also be applied to other brain tumors.

• This approach uses real-time cognitive monitoring to guide tumor removal based on the patient’s individual brain connectome, preserving neurocognitive functions and quality of life.

• A multidisciplinary team—including neurosurgeons, anesthesiologists, and neuropsychologists or speech therapists—is essential for patient selection, preparation, and intraoperative mapping.

• The asleep–awake–asleep protocol with continuous cognitive testing and tailored tasks optimizes functional mapping and minimizes permanent deficits.

• Subpial dissection and limited coagulation reduce vascular injury and promote better cognitive outcomes.

• Early postoperative rehabilitation is crucial for neuroplasticity and functional recovery.

• Careful patient selection and preparation are vital; conditions impairing intraoperative testing are relative contraindications.

• This personalized surgical philosophy has led to high cognitive preservation, low permanent deficit rates, and high return-to-work rates.

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Surgical outcomes for spinal arachnoid cysts and webs: a case series

Acta Neurochirurgica (2025) 167:248

This retrospective case series found that surgical treatment for spinal arachnoid cysts (SAC) and webs (SAW) resulted in favorable outcomes (mMC I-II) in 90% and 83% of patients, respectively, with low complication and recurrence rates. Surgery should be considered for symptomatic patients.

• Spinal arachnoid cysts (SAC) and spinal arachnoid webs (SAW) are rare intradural pathologies causing pain and myelopathic symptoms.

• MRI is the main diagnostic tool, but distinguishing between SAC and SAW can be difficult; both may show the “scalpel sign”.

• This retrospective study reviewed 35 patients (29 SAC, 6 SAW) treated surgically from 2011–2023.

• Most patients presented with pain, gait disturbance, sensory, or motor deficits; preoperative neurological status was often not severe.

• Surgical treatment (fenestration or resection) led to favorable outcomes (mMC I-II) in 90% of SAC and 83% of SAW patients.

• Complications occurred in 14.7% of SAC cases but resolved without lasting deficits; no complications in SAW group.

• Recurrence was rare (2.7% in SAC, none in SAW) during short-term follow-up.

• Surgery is recommended for symptomatic patients, with generally favorable short-term results, but larger and longer-term studies are needed.

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Microsurgical Resection Versus Stereotactic Radiosurgery for Trigeminal Schwannoma: A Meta-Analysis of 949 Patient Treatment Outcomes

Neurosurgery 97:545–558, 2025

Meta-analysis of 949 trigeminal schwannoma patients found stereotactic radiosurgery (SRS) led to greater improvement in facial hypesthesia and motor deficits, but surgery was superior for facial pain relief. Both approaches provided similar tumor control. Treatment should be individualized based on patient characteristics, tumor profile, and symptoms.

• Trigeminal schwannomas (TS) are rare, benign nerve sheath tumors, with no clear consensus on optimal treatment between surgical resection and stereotactic radiosurgery (SRS).

• Meta-analysis included 29 retrospective studies with 949 patients: 589 had SRS, 360 had surgery; larger tumors were more likely to be treated surgically.

• SRS led to significantly higher rates of facial hypesthesia (numbness) improvement (44% vs 12%) and lower rates of new hypesthesia (4% vs 15%) compared to surgery.

• Surgery was more effective for improving facial pain (81% vs 58% after SRS).

• Both SRS and surgery provided high and similar tumor control rates (89% SRS vs 91% surgery).

• Trigeminal motor function improved more after SRS, but data were limited.

• Treatment choice should be individualized, considering tumor size, patient characteristics, and presenting symptoms.

• Limitations include retrospective design, heterogeneous data, and lack of standardization for outcome measures.

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Training on a 3D-Printed Simulation Model Improves Accuracy in External Ventricular Drain Placement

Operative Neurosurgery 29:418–427, 2025

Training neurosurgeons on a 3D-printed simulation model with a standardized protocol significantly improved external ventricular drain (EVD) placement accuracy, reduced variability, and increased confidence, benefitting both junior and experienced practitioners. Regular simulation-based training is recommended to maintain high clinical performance and standardize EVD procedures.

• 3D-printed head models were developed for training neurosurgical residents in external ventricular drain (EVD) placement.

• Training included pre-training, standardized protocol with neuronavigation, and post-training rounds.

• EVD placement accuracy improved significantly after training, with optimal placement rates rising from 55% to 84%.

• Distances to ideal entry and target points, as well as procedure times, were significantly reduced post-training.

• Experience alone did not predict accuracy; even senior neurosurgeons improved, and post-training results were similar across experience levels.

• Right-handed participants achieved better outcomes using their right hand for both sides; left-sided EVDs were more often misplaced.

• Participants’ confidence in EVD placement and direction increased after training.

• Regular, standardized simulation training is recommended for all neurosurgeons, regardless of experience, to maintain high clinical performance.

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Surgery for mesial temporal pathology: a 26-year experience

J Neurosurg 143:738–747, 2025

Over 26 years, keyhole craniotomy via the inferior temporal gyrus for mesial temporal lobe surgery showed a low complication rate (5.3%), with only 0.3% permanent neurological deficits. Technique refinement and perioperative strategies minimized risks, supporting this approach as safe and effective for temporal lobe pathology.

A 26-year, single-surgeon study reviewed 717 mesial temporal lobe (MTL) surgeries using a keyhole inferior temporal gyrus (ITG) approach for epilepsy and other pathologies.

• Overall complication rate was low (5.3%), with only 0.3% of patients experiencing permanent neurological deficits and no perioperative deaths.

• Most common complications were hemorrhage (1.5%), postoperative seizure (1.3%), and cosmetic defects (0.6%).

• Neurological complications included transient cranial nerve deficits, visual field deficits, and speech difficulty, all rare.

• No significant correlation found between complications and age, sex, pathology type, operative time, or blood loss.

• Technical strategies such as meticulous closure, careful muscle reapproximation, and limiting brain retraction reduced complications over time.

• The ITG keyhole approach provided safe, effective, and cosmetically favorable access to the MTL, with complication rates improving as technique and teaching matured.

• Long-term follow-up (97% at 36 months) confirmed sustained safety and efficacy of this approach.

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Long-term outcomes after microvascular decompression for glossopharyngeal neuralgia

Neurosurg Focus 59(3):E19, 2025

Microvascular decompression (MVD) without neurectomy is effective and safe for glossopharyngeal neuralgia (GPN), with 86% long-term pain freedom and minimal complications. Pain location or radiation did not affect outcomes. Redo MVD is effective for persistent neurovascular compression. High-resolution MRI is useful for preoperative assessment.

• Microvascular decompression (MVD) without neurectomy is effective for glossopharyngeal neuralgia (GPN), including redo procedures.

• In a cohort of 29 patients, 86% were pain free at long-term follow-up (mean 65.3 months); 83% were immediately pain free post-op.

• Complication rates were low: 10% immediate and 11% long-term, with mostly mild symptoms.

• Redo MVD was successful in 3 out of 4 patients with persistent neurovascular compression after prior procedures.

• Pain location or direction of radiation did not affect pain outcomes after MVD.

• Most patients had neurovascular compression (NVC) visible on preoperative MRI, commonly involving the posterior inferior cerebellar artery (PICA).

• MVD is effective even in elderly patients and those with failed prior treatments, provided NVC is present.

• Findings support MVD as a primary treatment for classical GPN, guiding patient selection and management.

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The neuronal reserve in glioma surgery: functional reorganization of the motor network examined by navigated transcranial magnetic stimulation and diffusion tensor imaging tractography

J Neurosurg 143:793–804, 2025

This study demonstrates that glioma-induced reorganization of the motor cortex, measured by navigated transcranial magnetic stimulation and diffusion tensor imaging, is linked to functional recovery. Individual neuronal reserve—reflected in motor area resizing, excitability, and tract integrity—may explain differences in disease progression and surgical outcomes.

• Glioma surgery outcomes vary due to individual differences in motor network compensation and adaptation.

• This study used navigated transcranial magnetic stimulation (nTMS) and diffusion tensor imaging (DTI) tractography to measure motor cortex reorganization in glioma patients.

• Motor area relocation, resizing, and changes in excitability were observed in both affected and unaffected hemispheres, indicating bilateral reorganization.

• Greater preoperative motor area size and excitability were associated with better postoperative motor function and recovery.

• Reduced integrity of the corticospinal tract correlated with motor impairment and limited reorganization capacity.

• Functional recovery was linked to increased motor area size, excitability, and area relocation, supporting the concept of an individual neuronal reserve.

• Reorganization patterns were independent of tumor grade, highlighting the importance of personalized risk stratification and treatment planning.

• The study recommends using nTMS data for tailored preoperative risk assessment and patient counseling in glioma surgery.

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Dynamic Tumor in Situ Fluid Circulating Tumor DNA Postsurgery Effectively Predicts Recurrence and Clinical Benefits for Glioblastomas

Neurosurgery 97:671–680, 2025

Dynamic monitoring of tumor in situ fluid circulating tumor DNA (TISF-ctDNA) after glioblastoma surgery predicts recurrence earlier than imaging, effectively identifies molecular residual disease, and serves as a robust prognostic biomarker. TISF-ctDNA status guides treatment response assessment and may enable more personalized, timely interventions for GBM patients.

• TISF-ctDNA (tumor in situ fluid circulating tumor DNA) is a promising biomarker for monitoring molecular residual disease (MRD) and recurrence in glioblastoma (GBM) patients after surgery.

• In a prospective study of 37 GBM patients, TISF-ctDNA positivity after surgery was detected in 62.2% of cases and predicted a higher risk of recurrence and shorter progression-free survival (PFS).

• TISF-ctDNA positivity preceded imaging-detected recurrence by a median of 71 days, allowing for earlier intervention.

• Conversion from TISF-ctDNA positive to negative during adjuvant therapy was associated with improved overall survival.

• TISF-ctDNA showed high sensitivity (86.2%) and specificity (100%) in detecting postsurgical MRD recurrence.

• Common tumor gene mutations (EGFR, TP53, PTEN, NF1) did not significantly impact prognosis in this cohort.

• TISF-ctDNA monitoring is less effective for detecting distant tumor recurrences.

• The study supports TISF-ctDNA as an early, noninvasive tool for personalized GBM management, though larger studies are needed for validation.

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Does Anterior Lumbar Interbody Fusion Reduce Mechanical Complication and Pseudarthrosis Rate at the Lumbosacral Junction in Adult Spinal Deformity Surgery in Comparison to Posterior Lumbar Interbody Fusion?

Int J Spine Surg 2025, 19 (4) 409-417

In adult spinal deformity surgery, anterior lumbar interbody fusion (ALIF) at the lumbosacral junction significantly reduces mechanical complications, pseudarthrosis, and reoperation rates compared to posterior lumbar interbody fusion (PLIF), suggesting ALIF should be preferred unless direct posterior decompression is necessary.

• ALIF (anterior lumbar interbody fusion) at the lumbosacral junction significantly reduces mechanical complications and pseudarthrosis rates compared to PLIF (posterior lumbar interbody fusion) in adult spinal deformity (ASD) surgery.

• ALIF is associated with lower rates of implant-related pain and reoperation than PLIF.

• PLIF is an independent risk factor for mechanical complications in long-segment ASD constructs.

• ALIF results in significantly less blood loss, fewer transfusions, and shorter ICU and hospital stays than PLIF.

• ALIF provides superior biomechanical stability and fusion rates, likely due to better endplate preparation and larger cage footprint.

• PLIF remains suitable for cases requiring direct neural decompression, such as severe stenosis or spondylolisthesis.

• Surgical technique selection should consider patient anatomy, surgical goals, and specific pathology at the lumbosacral junction.

• Study limitations include retrospective design, single-center data, and potential selection bias; further multicenter studies are needed.

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The First Grade III Lumbar Spondylolisthesis Treated With the Novel 360° Artificial Disc/Artificial Facet Replacement Solution

Int J Spine Surg 2025, 19 (4) 362-369

This case report describes the first use of a combined 360° motion-preserving surgery—utilizing Prodisc L Artificial Disc and TOPS facet replacement—for grade III lumbar spondylolisthesis, showing rapid pain relief, improved function, and high patient satisfaction, suggesting a potential alternative to spinal fusion for select patients.

• First reported case of grade III lumbar spondylolisthesis treated with a novel 360° motion-preserving solution combining Prodisc L Artificial Disc Replacement and the Premia TOPS System.

• Traditional treatment is spinal fusion, but it reduces motion and can cause adjacent segment disease, especially problematic for younger, active patients.

• The patient, a 36-year-old man with progressive L5-S1 grade III spondylolisthesis and severe disc collapse, had failed conservative therapy and declined fusion.

• Surgery was performed in two stages: anterior artificial disc replacement, followed by posterior facet replacement with the TOPS device.

• Significant improvements were seen in pain, function, and satisfaction, with the patient pain-free and highly satisfied by 3 and 9 months post-op.

• This case suggests the 360° arthroplasty approach may offer a motion-preserving alternative to fusion for high-grade spondylolisthesis.

• Further research and long-term data are needed to confirm safety, durability, and broader effectiveness.

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How to deal with the superior petrosal vein in microvascular decompression for trigeminal neuralgia?

Neurosurg Focus 59(3):E12, 2025

Sectioning the superior petrosal vein at its main trunk while maintaining venous crossflow is a safe and effective strategy during microvascular decompression for trigeminal neuralgia, improving surgical access without significantly increasing venous-related complications, according to a large retrospective study.

• Management of the superior petrosal vein (SPV) during microvascular decompression (MVD) for trigeminal neuralgia (TN) is controversial, with concerns about operative field access and potential complications.

• A retrospective study evaluated a technique of SPV division at its main trunk near the superior petrosal sinus, maintaining venous crossflow through contributories, in 171 out of 217 patients (79%).

• No statistically significant increase in venous-related complications was observed in the SPV division group compared to the preservation group.

• Only 3 possibly venous-related complications occurred in the SPV division group, all of which were mild and transient.

• Anatomical variations of the SPV require careful intraoperative assessment and preservation of collateral venous drainage for safety.

• Preoperative imaging and intraoperative techniques (e.g., indocyanine green angiography) are recommended to assess collateral flow before SPV division.

• The study concludes that SPV division at the main trunk with preservation of crossflow is a safe strategy that improves surgical exposure during MVD for TN.

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Comparison of outcomes after anterior versus posterior surgery for degenerative cervical myelopathy

The Spine Journal 25 (2025) 1964−1973

This pooled analysis of 980 DCM patients found that anterior surgical decompression led to greater improvements in quality of life and disability at 1 year compared to posterior surgery, especially in mild cases. Anterior surgery had higher dysphagia risk; posterior surgery had more wound infections and pseudoarthrosis.

• Anterior surgical decompression for degenerative cervical myelopathy (DCM) leads to greater improvements in 1-year patient-reported quality of life and disability compared to posterior decompression.

• The benefit of anterior surgery is especially pronounced in patients with mild DCM, with significantly better outcomes in physical function, disability, and functional status.

• Improvements with anterior surgery are mainly driven by reductions in pain and enhanced ability to engage in recreational and physical activities.

• Dysphagia is more common after anterior surgery, while pseudoarthrosis and wound infections are more frequent after posterior surgery.

• No significant differences were found between the two approaches in mental health outcomes or overall neurological improvement as measured by mJOA and SF36-MCS.

• The study pooled data from three large, prospective multicenter clinical trials, analyzing 980 surgical patients with DCM.

• Results were robust across multiple sensitivity analyses and consistent with recent real-world and meta-analytic studies.

• The findings help inform surgical decision-making but do not dictate a single preferred approach for all patients.

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Trigeminal neuralgia or hemifacial spasm due to vertebrobasilar dolichoectasia

Neurosurg Focus 59(3):E6, 2025

Microvascular decompression (MVD) is the most effective treatment for trigeminal neuralgia and hemifacial spasm caused by vertebrobasilar dolichoectasia, offering higher symptom resolution and lower recurrence than radiosurgery or medication. Endoscope-assisted MVD reduces complications. Interposition and transposition surgical techniques show similar efficacy and recurrence rates.

• Vertebrobasilar dolichoectasia (VBD) is a rare vascular disorder that can compress cranial nerves, most commonly causing trigeminal neuralgia (TN) and hemifacial spasm (HFS).

• Microvascular decompression (MVD) is the most effective treatment, achieving symptom resolution in 87.3% of cases and having the lowest recurrence rate (6.5%) compared to radiosurgery and medication.

• Radiosurgery offers symptom relief in 63.7% of patients but has a high recurrence rate (47.2%) and is mainly used when surgery is contraindicated.

• Endoscope-assisted MVD significantly reduces complication rates (5.3% vs 23.8% with microscope) but does not improve symptom resolution compared to microscope-assisted surgery.

• Interposition and transposition techniques for nerve decompression show similar efficacy and recurrence rates, with no significant differences in complications.

• Nonsurgical treatments (medication, botulinum toxin, etc.) rarely result in full symptom resolution and are generally insufficient as standalone therapies.

• Multiple vessels (AICA, PICA, SCA) can be involved in nerve compression in VBD, affecting surgical planning and outcomes.

• Most patients experience long delays (mean 4–4.5 years) before diagnosis, and VBD-related cranial neuropathies remain challenging to manage due to anatomical complexity and limited high-quality evidence.

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Ventricular Entry During Glioblastoma Resection is Associated With Reduced Survival and Increased Risk of Distant Recurrence

Neurosurgery 97:601–611, 2025

Ventricular entry (VE) during glioblastoma resection is an independent risk factor for reduced overall survival and increased distant recurrence, including leptomeningeal dissemination. VE may diminish the survival benefit of gross-total resection, especially in tumors contacting the subventricular zone. Surgical strategies should weigh VE risks against maximal tumor removal.

• Ventricular entry (VE) during glioblastoma (GBM) resection is associated with significantly reduced overall survival (OS) and increased risk of distant recurrence and leptomeningeal dissemination (LMD), independent of other prognostic factors.

• Patients with VE had a median OS of 12 months versus 18 months for non-VE, and higher rates of distant recurrence (63.9% vs 39.7%).

• VE is more common in tumors contacting the subventricular zone (SVZ), and even among these, VE further reduces survival (12 vs 17 months).

• Gross-total resection (GTR) without VE provides the longest survival; GTR with VE does not significantly improve survival over less extensive resections with VE.

• VE is also associated with higher rates of postoperative hydrocephalus and need for external ventricular drains.

• Mechanistically, VE may facilitate tumor cell seeding into cerebrospinal fluid, promoting multifocal recurrences and LMD.

• Neurosurgeons should carefully weigh the risks of VE against the benefits of maximal tumor resection in surgical planning.

• Further prospective, multicenter studies are needed to clarify the risks and guide surgical strategies for GBM involving the SVZ.

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Spinal Cord Tract Integrity in Degenerative Cervical Myelopathy

Neurosurgery 97:681–690, 2025

This study used diffusion tensor imaging to assess spinal cord tract integrity in degenerative cervical myelopathy (DCM). Significant injury was found in the lateral corticospinal tract, fasciculus gracilis, and fasciculus cuneatus, suggesting these are key tracts affected in DCM, while other tracts may support compensatory recovery.

• Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction, often resulting in persistent motor deficits despite surgery.

• This study used diffusion tensor imaging (DTI) and atlas-based analysis to assess specific spinal cord tract integrity in DCM patients versus healthy controls.

• Fractional anisotropy (FA) was significantly reduced in the lateral corticospinal tract, fasciculus gracilis, and fasciculus cuneatus in DCM patients compared to healthy volunteers.

• No significant FA differences were found between mild and moderate-to-severe DCM patients for any tract.

• Most other spinal tracts, including reticulospinal and rubrospinal, showed no significant FA changes, suggesting possible preservation and compensatory potential.

• Limitations include small sample size, age differences between groups, and inability to analyze tracts at the site of maximal compression.

• Findings suggest injury to specific tracts in DCM, with other tracts as potential targets for future therapies and compensatory recovery.

• Further studies with larger cohorts and improved imaging are needed to validate and expand these results.

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Microsurgical management of 883 previously coiled intracranial aneurysms

J Neurosurg 143:654–667, 2025

This systematic review and meta-analysis found that microsurgical management of previously coiled intracranial aneurysms is effective and safe in well-selected patients, achieving high complete occlusion and good functional outcomes, especially with delayed direct clipping, small aneurysm size, and anterior location.

• Microsurgical management of previously coiled intracranial aneurysms (IAs) is effective and safe in well-selected patients.

• Meta-analysis included 874 patients with 883 previously coiled IAs; most underwent direct clipping.

• Complete occlusion rate was 97.2%, good functional outcome 82.9%, and perioperative mortality 3.7%.

• Direct clipping had the best safety and efficacy, with the lowest rates of complications and highest rates of good outcomes.

• Smaller, anteriorly located, and unruptured aneurysms were associated with the most favorable outcomes.

• Early microsurgery (within 1 month of coiling) and Gurian group C IAs had higher perioperative death rates.

• Key management factors: IA size, location, rupture status, indication, and timing/type of microsurgery.

• Most studies were retrospective case series, limiting subgroup analysis and introducing some heterogeneity.

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Predictive models for assessing the risk of brain aneurysm rupture

J Neurosurg 143:607–614, 2025

This study evaluated predictive models for brain aneurysm rupture risk using clinical, morphological, and advanced MRI radiomics data. Models combining these factors, especially radiomics, significantly improved accuracy in identifying symptomatic aneurysms, supporting a comprehensive, personalized approach for aneurysm risk stratification and treatment decisions.

• The study evaluated predictive models for assessing the risk of brain aneurysm rupture using high-resolution MRI, clinical, morphological, and radiomic data.

• 129 intracranial aneurysms were analyzed; 26% were symptomatic (ruptured or with warning symptoms).

• The PHASES score alone had low predictive ability (AUC 0.61–0.62) for symptomatic aneurysms.

• Adding morphological metrics (especially size ratio) and smoking status improved prediction (AUC up to 0.79).

• Incorporating aneurysm wall enhancement (AWE) metrics further increased model performance (AUC 0.82).

• The best model included age and radiomics features, achieving the highest predictive accuracy (AUC 0.87, 88% sensitivity).

• Younger age, current smoking, larger size ratio, and higher wall enhancement were associated with symptomatic aneurysms.

• A comprehensive approach using clinical, morphological, and advanced imaging/radiomics data improves aneurysm risk stratification.

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Conservative management of 661 patients with unruptured intracranial aneurysms: an observational study over 4 decades

J Neurosurg 143:641–653, 2025

This retrospective study of 661 patients with unruptured intracranial aneurysms found a 4.4% aneurysm-related mortality and 0.6% annual rupture rate. No ruptures occurred with PHASES <8 or ELAPSS <15, highlighting these thresholds for risk stratification and the importance of close follow-up, especially in the first 10 years.

• A retrospective study analyzed 661 patients with 767 unruptured intracranial aneurysms (UIAs) managed conservatively over 4 decades.

• The overall aneurysm-related mortality rate was 4.4%, with 3.5% of patients experiencing rupture; annual hemorrhage rate was 0.6%.

• Most ruptures (87%) occurred within the first 5 years after diagnosis; no ruptures were observed after 10 years.

• No ruptures or aneurysm-related deaths occurred in patients with PHASES score <8 or ELAPSS score <15.

• Independent predictors of rupture included aneurysm size, PHASES and ELAPSS scores, posterior circulation location, and age ≥70 years.

• Aneurysms <7 mm in diameter did not rupture in this cohort, but this may reflect selection bias.

• Lifelong regular follow-up is recommended for conservatively managed UIAs, especially in the first 10 years.

• PHASES and ELAPSS score thresholds can help identify high-risk patients who may benefit from treatment.

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Less is more: complication rates and outcome measures of intradiscal osteotomy versus pedicle subtraction osteotomy in adult spinal deformity

J Neurosurg Spine 43:313–323, 2025

In adults with spinal deformity, intradiscal osteotomy (IDO) is as effective as pedicle subtraction osteotomy (PSO) for lordosis restoration and sagittal balance, with similar complication rates but significantly less blood loss, shorter operative time, and less postoperative back pain at 3 months.

• Intradiscal osteotomy (IDO) and pedicle subtraction osteotomy (PSO) are both used to correct adult spinal deformity, aiming to restore lumbar lordosis and sagittal balance.

• IDO and PSO showed similar fusion rates and complication profiles, with no statistically significant difference in rates of proximal junctional kyphosis, hardware failure, DVT, wound infection, or pseudarthrosis.

• IDO resulted in significantly less estimated blood loss (800 ml vs. 1400 ml) and shorter operative time (7 vs. 8.5 hours) compared to PSO.

• IDO patients reported less back pain at 3 months post-op (VAS 1 vs. 3, p=0.01) than PSO patients.

• Both techniques effectively restored lumbar lordosis, but IDO achieved better postoperative sagittal vertical axis (SVA) correction (5 cm vs. 7 cm, p=0.01).

• Higher BMI was a significant risk factor for postoperative complications in both groups.

• IDO is less technically complex, preserves vertebral body integrity, and is more familiar to spine surgeons than PSO.

• IDO can be considered an effective and potentially safer alternative to PSO for selected adult spinal deformity patients.

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Validation of Härtel Surface Anatomical Landmarks for Locating the Foramen Ovale: A Computed Tomography Scan Analysis and Revised Technique Description

Operative Neurosurgery 29:399–407, 2025

CT-based validation of Hartel’s anatomical landmarks shows the foramen ovale is closer to the tragus and more medial than previously described. Revised needle trajectories, targeting 2–2.5 cm anterior to the tragus and between the inner canthus and midpupillary lines, may improve safety and accuracy in trigeminal procedures.

• Hartel surface anatomical landmarks for foramen ovale (FO) localization were assessed using CT scans in 99 adults (198 foramina).

• The FO is typically closer to the external auditory canal (mean 23.26 mm) and more medial (mean 25.43 mm from midline) than Hartel’s original description.

• FO is usually located between the eye’s inner canthus (IC) and midpupillary (MP) lines, not directly along the MP line as previously thought.

• Recommended needle trajectory: 2–2.5 cm anterior to tragus and targeting a point between the IC and MP lines, avoiding excessive medial/posterior displacement.

• A posteromedial “Danger Zone” exists within 20 mm of the midline and EAC, where vascular injury risk increases.

• Imaging guidance (fluoroscopy, CT) remains essential for safe and accurate needle navigation.

• These adjustments may improve procedural accuracy, safety, and patient outcomes for percutaneous trigeminal procedures.

• Further clinical and cadaveric validation is needed for these technique modifications.

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