Exoscope-assisted resection of spinal tumors: volumetric efficacy, safety and learning curve analysis in 47 consecutive cases

Objective To evaluate the clinical outcomes, volumetric extent of resection, safety profile, and skill acquisition dynamics of 3D-4K digital exoscope-assisted spinal tumor resection.Methods A retrospective analytical single-center study was conducted on 47 consecutive patients undergoing exoscope-assisted resection across intramedullary (IM, n = 7), intradural extramedullary (IDEM, n = 34), and extradural (ED, n = 6) compartments. Extent of resection was determined via blinded postoperative subtraction MRI. Surgical skill acquisition was modeled using sequential Cumulative Sum (CUSUM) analysis of intraoperative blood loss.Results Mean age was 49.1 ± 17.3 years (63.8% female). Overall Gross Total Resection (GTR > 95%) was achieved in 85.1% (n = 40/47), reaching 100% in IM lesions (n = 7/7) and 82.4% in IDEM tumors (n = 28/34, p = 0.567). Postoperative CSF fistula occurred in 6.4% (n = 3/47), restricted exclusively to IDEM Schwannomas. Median operative time was 3.27 hours (IQR: 2.68–5.05; n = 32/47). Median hospital stay was 3.0 days (IQR: 3.0–5.0). At 6-month follow-up, paired evaluations demonstrated significant functional and pain improvements (mMs and ODI/NDI, p < 0.001). Sequential CUSUM analysis identified a structural break at case 28, marking the transition to technical mastery without blood loss inflation during early cases (p = 0.553).Conclusions Resection of spinal tumors using the 3D-4K exoscope is safe, effective, and yields high volumetric resection rates. Skill acquisition follows a patient-safe learning curve, achieving technical proficiency at case 28.