Abstract
Fluorescence-guided surgery (FGS) has been increasingly adopted to improve intraoperative tumor visualization and the extent of resection in high-grade gliomas. However, concerns remain about whether enhanced visualization and more aggressive resection could lead to increased postoperative neurological deficits. We conducted a systematic review and meta-analysis to assess the neurological safety of fluorescence-guided surgery compared with conventional white-light (WL) surgery.
A systematic search of PubMed, Embase, and Scopus was performed from database inception to March 2026, following PRISMA guidelines. Studies comparing FGS (such as 5-aminolevulinic acid or fluorescein) with WL surgery and reporting postoperative neurological outcomes were included.
A total of 27 studies involving 3,241 patients (1,974 undergoing FGS and 1,267 undergoing WL) were included in the systematic review. Of these, 13 comparative studies were suitable for a quantitative analysis of postoperative neurological deficits. The combined analysis showed no significant difference in neurological deficit risk between FGS and WL surgery (RR=1.02, 95% CI 0.75–1.40; I² = 39.3%). Sensitivity analysis, excluding studies with zero events, produced similar results (RR=1.03, 95% CI 0.71–1.51; I² = 54.4%). Subgroup analysis by study design showed no significant differences between randomized controlled trials and observational studies (p for subgroup difference >0.05). The overall risk of bias was moderate, mainly due to confounding in observational studies, and the evidence was rated as low certainty.
In our analysis, FGS does not lead to more postoperative neurological deficits when compared to traditional white-light surgery. These results support its use as a safe addition to improve tumor visualization and enable maximal removal without compromising neurological function. Future research involving patient-reported outcomes is necessary to better understand the patient-centered benefits of fluorescence-guided techniques.
•Fluorescence-guided surgery maintains neurological safety despite enabling more aggressive resection•No significant difference in neurological deficits compared with white-light surgery•Consistent findings across study designs and sensitivity analyses•Provides clinical reassurance for the use of fluorescence-guided techniques•Emphasizes the importance of patient-centered outcomes in neurosurgical research