الفهرس 
Review of LiteratureOnly 14 pages are availabe for public view
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Abstract
Surgery plays an important role in the treatment of Low-Grade Glioma. A combination of techniques including neuronavigation, IONM, awake surgery, RTNT, intraoperative MRI, CT, ultrasonography, guidance will allow for safe and maximum surgical resection, resulting in better outcomes in terms of survival and postoperative functional recovery.
Neuronavigation alone proves to be an invaluable tool in low grade glioma regarding localization and EOR, but it alone might not be sufficient to achieve an acceptable safety for lesions that are diffuse and often close to eloquent areas as DLGG.
Safety vs Radicality in glioma surgery remains a challenging issue for the surgeon as well as the patient. Since GTR remains an independent factor to survival in patients suffering from DLGG, radicality should be the aim of all glioma surgeons, however as shown in several studies the KPS score of the patients’ remains a strong and an independent factor to prognosis of the patients with glial tumors272,640.
Concerning the fact that without brain shift compensation neuronavigation is not reliable during entire course of surgery248, it would be unethical to randomize patients to compare effectiveness of a conventional microscopic surgery versus a system that offers all advantages of standard neuronavigation with or without additional different IONM and localizations methods.
Our study concluded that using NNV, with or without other IONM techniques, and technologies we achieved a comparable EOR to some of the literature. At our institute the NNV device is still nascent but with an accrual of user experience and an improved learning curve and combined with other IONM modalities, the NNV is expected to burgeon and can be utilized to reach a better potential and surgical outcome.
Finally, regardless of all our technologies, surgical radicality and patients’ postoperative KPS status remain strong independent factors for overall survival. Neurosurgeons should have the insight to balance between the surgical radicality and post operative KPS score.
Study Limitations
The main limitation of our study was the small sample size (which led to smaller subgrouping of patients, e.g., WHO grades, surgery protocols, etc..), which limited an appreciable statistical data.
Another limitation was absence of randomization, we couldn’t randomize the population into NNV group vs. non NNV group, as we decided to omit such randomization of patients due to ethical reasons. As in other non-randomized studies using historical controls, we compared our EOR results to the literature, but in doing so, randomization and heterogenicity effects cannot be fully excluded. Additionally, another randomization related limitation, was the tools available to the surgeon: in occasions a surgeon had all the available tools at hand (e.g., the IONM modalities, HGW, awake surgery), while in other occasions the surgeon had only the NNV device.
Finally, there was a bias from the patients and surgeons as aforementioned; Furthermore, there might be a bias from a potential learning effect, despite the fact that all the main surgeons had previous experiences with awake/asleep, IONM and NNV guided resections of gliomas, there might be bias in the learning curve while using the NNV, as it is a newly introduced device to our institute, so the earlier patients in the study had a less “NNV experienced” surgeon with less other IONM devices vice versa the patients near the end of the study.