Multidisciplinary practice in vestibular schwannoma surgery over a decade: optimizing facial nerve and hearing outcomes and analyzing the predictive role of tumor-related radiological features

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OBJECTIVE: Satisfactory facial nerve (FN) and hearing preservation rates associated with modern vestibular schwannoma (VS) surgery potentially reflect the surgeon's expertise established over years. While advanced MRI can estimate cranial nerve topography and tumor traits, radiological predictors of postoperative functional outcomes across three standard surgical approaches remain unclear. The aim of this study was to address this gap by determining independent radiological predictors of FN and hearing outcomes, stratified by surgical approach, while considering the influence of the surgeon learning curve stage. METHODS: The authors retrospectively reviewed patients with VS who underwent resection between July 2012 and July 2023 at their institution. Potential radiological predictors of postoperative hearing and FN results were examined using multivariate regression analysis. To examine the learning curve impact on FN and hearing outcomes, the first 100 and first 24 operated cases, respectively, were compared with the most recent cases. RESULTS: There were 187 patients (103 female, median age 52 years) included in this analysis. The median tumor size and fundal CSF space (FCS) horizontal diameter were 17.7 mm and 3.2 mm, respectively. MRI revealed FCS presence in 67.9%, T2-weighted hyperintensity in 44.9%, and heterogeneous contrast enhancement in 28.8% of patients. Intraoperative FN monitoring (IOFM) showed favorable responses in 77.1% of patients, and V-wave preservation was confirmed by auditory evoked potential monitoring in 33.9%. The gross-total resection (GTR) rate was 66.3%. Favorable FN functional outcomes were observed in 73.3%, 83.3%, and 86.8% of patients at early, short-term, and long-term postoperative evaluations, respectively, with favorable IOFM being a consistent predictor. FCS presence (OR 2.94, 95% CI 1.06-8.14; p = 0.038) and GTR (92.1% vs 77.3%, p = 0.016) were independently correlated with superior early and long-term FN results, respectively. Subgroup analysis revealed that FCS presence predicted better short- and long-term FN outcomes only in retrosigmoid cases, whereas heterogeneous enhancement was correlated with worse results in translabyrinthine cases. Serviceable hearing was preserved, when attempted, in 41.7% of patients; higher trends were seen with FCS size ≥ 3 mm, nonheterogeneous tumors, retrosigmoid cases, and earlier surgeon experience. The learning curve stage was not correlated with overall FN outcomes. CONCLUSIONS: A multidisciplinary surgical team can achieve favorable FN and hearing results in neuromonitoring-guided VS surgery, regardless of the surgeon's learning curve stage. FCS presence was a positive prognosticator of FN outcomes in retrosigmoid cases, while the translabyrinthine approach offered inferior results in cystic tumors. Larger case-volume studies are warranted to reliably evaluate middle cranial fossa cases and hearing outcome predictors.

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