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Evaluation of Discrepancy Between Radiographic Success and Patient Satisfaction in Adult Spinal Deformity Surgery

Neurosurgery 97:821–828, 2025

Despite radiographic success in adult spinal deformity surgery, 24.1% of patients remained dissatisfied, mainly due to postoperative lumbar stiffness-related disability. Satisfaction was not linked to radiographic parameters but was independently predicted by the modified lumbar stiffness disability index, highlighting the importance of counseling patients about this trade-off.

• About 24.1% of patients were dissatisfied with adult spinal deformity (ASD) surgery despite radiographic success.

• Radiographic success was defined as optimal alignment, no mechanical complications, and no revision surgery.

• Patient satisfaction was measured using SRS-22; scores <4.0 indicated less satisfaction.

• Clinical outcomes (pain, disability, quality of life) improved after surgery, but lumbar stiffness (M-LSDI) worsened.

• No significant differences in radiographic parameters were found between satisfied and less satisfied groups.

• High postoperative lumbar stiffness (M-LSDI score) was the single independent risk factor for dissatisfaction.

• Longer fusion length was associated with higher lumbar stiffness and lower satisfaction.

• Patients should be informed about the trade-off between pain relief and increased lumbar stiffness before surgery.

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Novel Delivery System Significantly Improves Technical Success and Safety of the Endovascular Clip System (eCLIPs) While Maintaining Efficacy for the Treatment of Wide-Necked Bifurcation Aneurysms

Neurosurgery 97:963–970, 2025

A prospective registry study found that the new eCLIPs electrolytic bifurcation system (eB) for wide-necked bifurcation aneurysms significantly improved technical success and safety over the prior generation, while maintaining high efficacy, with 96% satisfactory occlusion and low rates of neurological complications and retreatment.

• The eCLIPs device is an endovascular implant designed to treat wide-necked bifurcation aneurysms (WNBAs).

• This study compares two generations: the first-generation eCLIPs bifurcation remodeling system (eBRS) and the newer eCLIPs electrolytic bifurcation system (eB).

• A prospective registry included 280 patients; the eB system showed higher implantation success (92% vs 81% for eBRS, P = .007).

• Both systems achieved high rates of satisfactory aneurysm occlusion (mRROC 1+2: 96%).

• The eB system had lower all-cause (1.1%) and neurological (0.5%) death rates compared to eBRS (7% and 5%, respectively).

• Stroke and repeat procedure rates were low for both devices, with eB performing better (stroke: ~1.7%, repeat procedure: 2.2% vs 8.9% for eBRS).

• eCLIPs compares favorably in safety and efficacy to other devices like WEB and stent-assisted coiling.

• The eB system offers improved procedural success and safety, making eCLIPs a strong option for WNBAs; further studies are recommended.

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Volume of parasagittal dura is associated with blood markers of systemic inflammation

Acta Neurochirurgica (2025) 167:255

Higher blood C-reactive protein (CRP), a marker of systemic inflammation, is significantly correlated with lower volume of the parasagittal dura (PSD). This suggests PSD volume may serve as a potential imaging marker of systemic inflammation. No significant association was found between PSD volume and subjective sleep quality.

• The study investigated the relationship between the volume of the parasagittal dura (PSD) and blood markers of systemic inflammation, mainly C-reactive protein (CRP).

• 76 patients underwent intrathecal contrast-enhanced MRI to measure PSD volume and CSF clearance, alongside blood tests for inflammatory markers.

• Higher CRP levels were significantly correlated with lower PSD volume, suggesting an association between systemic inflammation and PSD morphology.

• This inverse relationship was significant even after adjusting for confounders such as age, sex, and diagnosis.

• Other blood markers (hemoglobin, erythrocyte volume fraction) showed initial correlations with PSD volume, but these were not significant after accounting for confounders.

• Impaired sleep quality was associated with higher CRP but not with PSD volume.

• The findings suggest PSD volume may serve as a potential imaging marker of systemic inflammation, but causality remains unclear.

• Further research is needed to clarify mechanisms and clinical implications of the PSD-inflammation link.

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Intraoperative vancomycin for preventing infection after open spine surgery: a systematic review and meta-analysis of randomized controlled trials

J Neurosurg Spine 43:509–518, 2025

A meta-analysis of seven randomized controlled trials found that intraoperative vancomycin use in open spine surgery did not significantly reduce rates of superficial or deep surgical site infections. Further large-scale studies are needed to clarify its efficacy and inform clinical guidelines.

• A systematic review and meta-analysis of 7 randomized controlled trials (RCTs) with 2235 patients assessed the efficacy of intraoperative vancomycin in preventing infections after open spine surgery.

• No significant reduction in overall surgical site infections (SSI), deep infections, or superficial infections was found with intraoperative vancomycin compared to control.

• Subgroup analyses showed no benefit in either instrumented or uninstrumented spine surgeries.

• There was no significant shift toward gram-negative or culture-negative infections with vancomycin use.

• Potential risks include local cytotoxicity and possible impairment of bone healing and spinal fusion.

• Current evidence is limited by small sample sizes, heterogeneity in vancomycin administration, and variable follow-up durations.

• The study concludes intraoperative vancomycin may not reduce infection risk and further large RCTs are warranted.

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Which interbody device minimized nonunion, subsidence, and reoperation after anterior cervical discectomy and fusion?

J Neurosurg Spine 43:453–463, 2024

This meta-analysis found that allograft spacers in anterior cervical discectomy and fusion (ACDF) result in lower nonunion and revision rates compared to PEEK cages, with no significant difference in subsidence risk. Allograft offers enhanced fusion and minimizes revision without increasing subsidence.

• Allograft and PEEK cages are the most commonly used interbody spacers in anterior cervical discectomy and fusion (ACDF), replacing autograft due to lower donor site morbidity.

• This meta-analysis included 10 studies with 1462 patients comparing allograft and PEEK cages for ACDF, analyzing nonunion, subsidence, and reoperation rates.

• Allograft showed a significantly lower rate of nonunion than PEEK cages (OR 0.33, p = 0.01), indicating better fusion outcomes.

• Reoperation due to nonunion was significantly higher with PEEK cages compared to allograft (OR 0.28, p < 0.01), but overall reoperation rates for any cause were not significantly different.

• No significant difference was found in the incidence or amount of subsidence between allograft and PEEK cages.

• Allograft’s osteoconductive properties likely contribute to its higher fusion rate, while PEEK cages may lead to fibrous interface formation, reducing solid fusion.

• Meta-regression showed no significant effect of smoking, age, or number of fused levels on nonunion rates.

• Conclusion: Allograft is advantageous over PEEK cages in ACDF due to higher fusion rates and lower revision risk, without increasing subsidence

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Outcome comparison between interposition and “contactless” transposition microvascular decompression approaches for trigeminal neuralgia

J Neurosurg 143:970–981, 2025

This study compared interposition and “contactless” transposition (Teflon and pericranial sling) microvascular decompression techniques for trigeminal neuralgia. Both were effective, but sling transposition showed improved midterm pain control and fewer complications. The only significant predictor of pain freedom was MRI evidence of clear nerve compression.

• Microvascular decompression (MVD) is a main surgical treatment for trigeminal neuralgia (TN), traditionally using Teflon interposition between nerve and artery.

• Recurrence of TN pain after MVD is often due to Teflon complications, prompting the development of “contactless” transposition techniques such as Teflon and pericranial sling transpositions.

• This retrospective study compared outcomes of interposition, Teflon transposition, and pericranial sling transposition in 305 TN patients.

• Sling transposition was mainly used for severe compression by the superior cerebellar artery and involved securing the artery to the tentorium with a pericranial graft.

• All techniques had similar short-term pain relief and complication rates, but sling transposition showed significantly higher pain-free rates at 2 years compared to other methods.

• Clear vascular compression on MRI was the only significant predictor of pain freedom in multivariate analysis.

• Sling transposition uses autologous tissue, avoids foreign body reactions, and may provide more durable pain control, but is technically more complex.

• Further long-term studies are needed to confirm the durability of sling transposition for TN pain control.

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Enhanced Recovery After Surgery Protocol for Microvascular Decompression in Trigeminal Neuralgia: A Retrospective Matched Cohort Study

Neurosurgery 97:936–944, 2025

Implementation of an enhanced recovery after surgery (ERAS) protocol for microvascular decompression in trigeminal neuralgia significantly reduced hospital length of stay, improved postoperative pain scores, and decreased transient hearing alterations compared to conventional care, without increasing complications, according to a retrospective matched cohort study.

• Enhanced Recovery After Surgery (ERAS) protocol was implemented for microvascular decompression (MVD) in trigeminal neuralgia (TN) patients and compared to conventional care in a retrospective matched cohort study.

• ERAS protocol included preoperative counseling, scalp block, small incisions, minimal muscle dissection, total intravenous anesthesia without narcotics, early enteral feeding, and early mobilization.

• 130 patients (65 ERAS, 65 non-ERAS) were analyzed after propensity score matching for key demographics and comorbidities.

• ERAS group had significantly shorter hospital length of stay (1.46 vs 2.95 days, P < .001) and lower postoperative verbal pain scores (1.63 vs 2.48, P = .03) than controls.

• ERAS patients experienced fewer transient postoperative subjective hearing alterations (0 vs 6 cases, P = .03).

• No significant difference in postoperative Barrow Neurological Institute (BNI) pain scores or major complications between groups.

• Subgroup analysis showed ERAS patients discharged at 24 hours had even lower pain scores than controls.

• Study limitations include retrospective design, small sample size, and use of subjective pain scores; larger randomized trials are needed.

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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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