Optimal Route in Thoracic Discectomy – a Meta-analysis of Anterior vs. Posterior Approaches

Introduction: Thoracic discectomy is commonly performed via anterior or posterior approaches, each with distinct risks and benefits. While the anterior approach allows direct access to ventral pathology, it’s associated with higher complication rates, fueling ongoing debate among neurosurgeons on optimal approach.

Methods: A systematic review and meta-analysis of 37 studies was conducted per PRISMA guidelines. We included observational and randomized studies, excluding emergency cases. Intraoperative and postoperative neurological outcomes, complications, and reoperations were analyzed. Additionally, operative time, estimated blood loss (EBL), and length of stay were pooled as surgical efficiency proxies.

Results: Data from 27,450 patients were pooled: 25% (6,794) approached anteriorly, 75% (20,656) posteriorly. No significant differences were found in neurological improvement (OR 1.47, 95% CI 0.8-2.72), worsening (OR 0.57, 95% CI 0.07-4.4), transient deterioration (OR 1.6, 95% CI 0.16-15.51), reoperations (OR 1.95, 95% CI 0.54-7.09), surgical site infections (OR 0.24, 95% CI 0.03-2.02), or CSF leakage (OR 1.54, 95% CI 0.24-9.99). Operative time was comparable (SMD 5.42 days, 95% CI -0.46 to 11.29). Mean EBL for anterior approaches was 600.1 mL (95% CI 246.99-953.23) vs. 1925.1 mL for posterior approaches (95% CI 837.32-3012.88). Despite higher EBL, the posterior approach had fewer overall complications (OR 3.11, 95% CI 2.33-4.15; p < 0.001; I2 = 21%) and shorter stays (SMD 0.48, 95% CI 0.25-0.71; p < 0.001; I2 = 59%).

Conclusion : The anterior approach may result in less bleeding but has higher complication rates, while the posterior approach correlates with shorter hospital stays. More research is needed to determine the optimal approach for each patient, accounting for potential biases.