Editorial: Doing more with less: neurosurgery strategies and tricks of the trade in the technological era
Year: 2026
Type: editorial
Abstract: In recent decades, advancements in technology -such as operating microscopes, endoscopes, image guidance systems, intraoperative neuromonitoring (IONM), ultrasonic surgical aspirators, fluorescenceguided surgery, indocyanine green video angiography, machine learning-based radiomics, and risk prediction models -have significantly improved the accuracy, predictability, and safety of neurosurgical operations, ultimately enhancing patient outcomes (Wang et al., Gu et al.). 1-4 More recently, augmented reality tools and simulators have opened new avenues for preoperative surgical planning, while advancements in artificial intelligence and related technologies hold promise for optimizing early detection methodologies and refining treatment algorithms. 1-3 However, a significant paradox remains: many of these technological innovations are still inaccessible in low-and middle-income countries (LMICs) (Doléagbénou et al., Zhang et al.). This has created an urgent clinical need for robust strategies that maximize surgical efficacy while minimizing resource consumption. 5,6 The theme of this Special Issue, "Doing More with Less: Neurosurgery Strategies and Tricks of the Trade in the Technological Era", addresses this challenge by exploring the integration of cutting-edge technologies to overcome neurosurgical hurdles, while emphasizing reliable, low-cost, and adaptive solutions suitable for resource-limited settings (Zhang et al.). 5-9 Furthermore, this issue highlights the development of novel predictive classifications, clinical algorithms, and decision-making systems aimed at optimizing resource allocation, preventing complications, and refining patient selection (Wang et al., Lv et al., Yuping et al.).The "Doing more with less" philosophy finds numerous applications in neurosurgery, and this Editorial synthesizes the contributing articles into six cohesive, subspecialty-specific themes presented by the authors, ultimately aiming to bridge the gap between technological advancements and practical implementation in diverse healthcare settings.Minimally invasive neurosurgery significantly reduces surgical morbidity, accelerates postoperative recovery, and shortens hospital stays. In a comprehensive comparative study, Jalal et al. (2026) evaluated the clinical efficacy of neuroendoscopic surgery (NS) versus stereotactic aspiration (SA) for spontaneous intraparenchymal hemorrhage (Jalal et al.). Analyzing a cohort of 199 patients (97 NS, 102 SA), the investigators found that NS achieved a significantly higher median percentage reduction in hematoma volume compared to SA across all studied brain regions (92.90% vs. 22.20%, p < 0.001). This rapid clot evacuation translated into a more pronounced post-operative GCS improvement (4.0 vs 0.5 points, p < 0.001). Most importantly, the direct visualization afforded by NS allowed for immediate intraoperative control of active bleeders, resulting in a reduced rate of symptomatic rebleeding (7.2% vs. 24.5%, p < 0.001) and a decrease in 30-day mortality (9.3% vs. 22.5%, p = 0.012) (Jalal et al.). 10-12 Similarly, Liu et al. (2026a) demonstrated the value of direct neuroendoscopic visualization in treating septated chronic subdural hematomas, where fibrous membranes impede conventional drainage. 13,14 Comparing 45 patients managed endoscopically with 52 managed via traditional burr hole drainage, they reported a dramatic reduction in postoperative recurrence in the endoscopic cohort (2.22% vs. 15.38%, p < 0.05) through systematic identification and fenestration of the fibrous septa (Liu et al.). However, it is essential to recognize that a surgical technique is not per se minimally invasive merely due to the tools used (e.g., an endoscope) or the incision size; rather, it is truly minimally invasive only if it effectively minimizes the retraction and manipulation of neurovascular structures, thereby managing the condition while preventing post-operative deficits. 15-18 In this context, Erginoglu et al. (2025b) challenged the conventional belief that the endoscopic approach (EA) is inherently less traumatic than open microsurgical techniques. By comparing the interhemispheric transcallosal approach (ITA; n = 13) against EA (n = 10) for third ventricle colloid cysts, volumetric segmentation on early postoperative T2/FLAIR MRI images revealed that EA produced significantly larger volumes of parenchymal edema along the surgical tract compared to ITA (2,951.51 ± 2,083.87 mm³ vs. 349.45 ± 218.48 mm³, p < 0.001). Furthermore, late postoperative MRI demonstrated that gliosis, encephalomalacia, and structural parenchymal loss were entirely absent in the ITA group but occurred in 50% of EA cases (p = 0.007), suggesting that transcortical rigid endoscopic trajectories can lead to permanent parenchymal changes. ITA also achieved a significantly higher gross total resection rate than EA (92% vs. 50%, p = 0.039) (Erginoglu et al.).For secondary cerebrospinal fluid (CSF) flow obstructions, selected cases may benefit from endoscopic techniques that offer elegant, shunt-free solutions, such as the endoscopic-assisted cisternostomy with Ommaya reservoir insertion for trapped temporal horn, effectively restoring physiological CSF pathways and avoiding the long-term complications associated with permanent ventriculoperitoneal shunting (AlSaiari et al.).The treatment of complex intracranial aneurysms necessitates continuous technical advancements. 1,3,19 For intricate posterior circulation pathologies, Mammadinova et al. (2025) detailed the "Stent-within-a-Stent" technique following telescopic flow diverter (FD) reconstruction for basilar artery aneurysms with preaneurysmal stenosis. This method stabilized the construct and effectively excluded the aneurysm, although the authors cautioned about the ischemic risks associated with multiple FDs in areas rich in perforators (Mammadinova et al.). Similarly, Zheng and Yu (2026) described the use of FD for complex mirror-like aneurysms located at the middle cerebral artery trifurcation, demonstrating that FD is a viable and effective alternative when traditional microsurgical clipping is not feasible (Zheng et al.).In recent decades, significant advancements in endovascular techniques have transformed the management of neurovascular diseases, while microsurgical approaches continue to evolve and maintain specific indications. Consequently, vascular neurosurgeons must uphold their technical proficiency in addressing these challenging lesions. 19-21 Erginoglu et al. (2025a) provided an intraoperative video analysis of the microsurgical clipping of a large, unruptured multilobular anterior communicating artery aneurysm associated with a vascular fenestration, emphasizing that fenestrations disrupt normal hemodynamic flow, thereby increasing the risk of aneurysm formation and surgical complexity. They highlighted essential technical strategies, including preemptive temporary clipping of the ipsilateral A1 segment to soften the aneurysm dome and high-magnification dissection to preserve the recurrent artery of Heubner and hypothalamic perforators (Erginoglu et al.).In cases of catastrophic neurovascular complications, immediate salvage techniques are crucial. Li et al.(2025) presented an emergency repair method for an internal carotid artery rupture during a supratentorial craniotomy for a recurrent pituitary adenoma, successfully sealing the defect with an autologous crushed muscle patch secured via micro-suturing, achieving immediate hemostasis while ensuring long-term vessel patency (Li et al.).Although cranial nerve syndromes are not classified as true neurovascular diseases, they arise from neurovascular conflicts where a compressing vessel affects the nerve, necessitating mastery of microsurgical techniques for effective and safe microvascular decompression.In cases of recurrent cranial nerve syndromes, repeat surgery presents significant challenges that require adaptive microsurgical techniques. Liu et al. (2026) evaluated repeat posterior fossa exploration and external neurolysis in 38 patients with recurrent trigeminal neuralgia following microvascular decompression. While re-exploration revealed Teflon adhesion in 92.1% of cases, complete pain relief was achieved in 92% immediately and 86.8% long-term; however, aggressive neurolysis posed a risk of facial numbness. To mitigate this risk, the authors successfully employed a "limited neurolysis" strategy-isolating the Teflon and carefully dissecting adhesions without excessively stripping the nerve-demonstrating a critical technical approach for managing complex revision cases (Liu et al.).The clinical significance of persistent embryonic pathways was comprehensively reviewed by Li and Yu (2026), focusing on the persistent primitive hypoglossal artery, which often serves as the sole hemodynamically critical arterial supply to the posterior circulation, underscoring the importance of its preservation during surgical or endovascular interventions (Li et al.). Ensuring patient safety during complex spinal and cranial operations requires precise intraoperative physiological feedback. Severe spinal deformity surgeries carry significant risks of spinal cord injury. To reduce false-positive monitoring alerts, Gao et al. ( 2026) evaluated the adjunctive benefit of monitoring MEP recovery and EMG activity during the wake-up phase in 111 high-risk patients experiencing intraoperative MEP alerts. The authors found that tracking electrophysiological recovery during arousal offers vital complementary data to the traditional, physically demanding wake-up test, thereby lowering false-positive rates and enhancing risk assessment (Gao et al.).In peripheral nerve surgery, the integration of technology improves functional preservation. Xing et al.(2026) explored the clinical utility of combining IONM with high-definition endoscopy during brachial plexus schwannoma resections. In a cohort of 20 patients, they achieved complete intracapsular enucleation with no permanent postoperative motor deficits, demonstrating that real-time electrical feedback, combined with close-up visualization, ensures meticulous nerve preservation (Xing et al.). This focus on electrophysiological safety was echoed in a complex functional craniotomy reported by Tan et al. (2025), where surgeons attained a complete surgical cure of intractable post-traumatic epilepsy caused by a retained intracranial foreign body (a conical bamboo stick penetrating the temporal base). By employing real-time cortical electroencephalography monitoring, the surgeons accurately mapped the epileptogenic zone, enabling safe, targeted cortical resection (Tan et al.).Intraoperative imaging has traditionally relied on high-cost, high-footprint intraoperative MRI; however, portable, real-time intraoperative ultrasonography (iUS) offers a cost-effective, high-utility alternative. 2026) evaluated the biomechanical and infectious risks of autologous versus synthetic dural closure materials specifically for U-shaped dural incisions in a retrospective cohort of 172 patients, comparing standard continuous suturing (Method 1) with pericranium-assisted duraplasty (Method 2), which is used when intraoperative dural shrinkage hampers tension-free approximation. While both methods achieved excellent rates of watertight sealing, pericranium-assisted duraplasty posed a significantly higher risk of sitespecific infections, particularly in the infratentorial compartment (12.82% overall infratentorial infection rate, p = 0.039). The authors emphasized that when utilizing autologous fascia, surgeons must carefully balance sealing efficacy against the increased local infection risk, especially in the posterior fossa (Wang et al.). This Special Issue also addresses the management of rare and severe traumatic emergencies, including a systematic review and case report by Liu et al. (2026c) on multiple thoracic vertebral compression fractures resulting from accidental low-voltage electric shock injury; they found that 75% of fractures were localized to the thoracic spine, where paraspinal muscle tetanic spasms impose extreme biomechanical stress, highlighting the importance of vigilance in diagnosing potential spinal fractures in individuals experiencing back pain after such injuries (Liu et al.). Furthermore, Yang et al. (2026) showcased clinical adaptability in a complex transorbital penetrating injury caused by a long bamboo stick that penetrated the orbit and extended into the nasopharynx, successfully extracting the organic foreign body through a minimally invasive, endoscopic endonasal approach, thereby avoiding significant collateral damage and ensuring excellent visual recovery (Yang et al.).The articles compiled within this Special Issue illustrate the multifaceted concept of "Doing More with Less" in today's technological landscape. Neurosurgery must balance the rapid adoption of advanced, highcost technological systems with the practical development of flexible, accessible, and cost-effective solutions. This includes the implementation of portable neurosonography in LMICs (Zhang et al.), the creation of universally accessible nutritional protocols in ERAS (Kaewborisutsakul et al.), the development of robust, laboratory-derived prognostic nomograms (Lv et al., Yuping et al.), or the enhancements of surgical authorization software (Haowei et al.). These studies emphasize that surgical excellence is fundamentally rooted in "clinical creativity", disciplined care, and meticulous technique. Looking ahead, the integration of artificial intelligence and digital health should prioritize bridging the global healthcare gap, ensuring that high-quality, safe, and precise neurosurgical care is accessible to patients across all socioeconomic backgrounds.
Source: Frontiers in Surgery
Language: English
Subfield: Clinical Neurology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,801
OpenAlex ID: W7223669926