Nerve Injuries in Craniofacial and Skull Base Surgery: Shared Mechanisms, Prevention, and Repair Strategies

Background: Craniofacial and skull base procedures place cranial nerves at risk of injury, with consequences for movement, sensation, hearing, swallowing, vision, and quality of life. Methods: This narrative review integrates 46 original publications with six targeted references added during revision, addressing injury mechanisms, prevention, postoperative assessment, reconstruction, and rehabilitation across neurosurgery, otolaryngology, and maxillofacial surgery. Results: Recurring mechanisms include traction, compression, ischemia, thermal injury, direct trauma, and transection. Neuromonitoring contributes to localization, functional surveillance, and prognosis when paired with reproducible baseline recordings, appropriate modality selection, technical troubleshooting, and a predefined surgical response to alerts. Preoperative and postoperative electrophysiological testing complements but does not replace intraoperative monitoring. Recognized transection favors immediate tension-free reconstruction when feasible; an anatomically continuous nerve with an unfavorable electrical response requires contextual interpretation rather than automatic sacrifice. Rehabilitation combines target-organ protection, selective motor or sensory retraining, symptom control, and patient-reported assessment. Conclusions: The practical distinction is between a potentially reversible functional disturbance and confirmed structural discontinuity. Management should link monitoring changes to corrective action, preserve viable nerves, and coordinate timely reconstruction with rehabilitation. Heterogeneous, predominantly observational evidence does not support universal alert thresholds, a single reconstruction deadline, or guaranteed functional recovery.