A Paradigm Shift in Salvage Surgery for Radiated Vestibular Schwannoma

Abstract

Determine whether more conservative management for surgical salvage after failed radiation leads to better facial nerve outcomes. "Retrospective" review using prospectively planned database. Private practice, tertiary neurotology/neurosurgery referral center. A series of 73 patients with vestibular schwannoma, who underwent primary radiosurgery with no other intervention and then surgical salvage tumor removal using the translabyrinthine approach. Translabyrinthine craniotomy for vestibular schwannoma salvage surgery after failed radiation, with either gross total or partial tumor removal. Long-term (1 yr) House-Brackmann (H-B) facial nerve grade and change in facial nerve grade from before to after surgery. Of the 73 patients, 79.5% had gross total removal, 5.5% had planned partial resection (subtotal or near total), and 15.1% had intraoperatively elected partial removal with most of these being near total removal. At 1 year of follow-up, good facial nerve function (H-B I/II) was found in 50% of patients with gross total removal and 85.7% of those with partial removal (p ≤ 0.03). The H-B grade was maintained postoperatively in 45.8% and 78.6% of the 2 groups, respectively (p ≤ 0.037), with 21.7% of the total removal group having unsatisfactory outcomes (H-B V or VI) compared with 7.1% of patients with partial removal. To date, no patient has required additional treatment. Failed radiosurgery is an increasing indication for salvage surgery in patients with posterior fossa tumors. A conservative approach with a willingness to perform partial and near-total tumor removals leads to better facial nerve outcomes with no current evidence of treatment compromise.