Comparable outcomes for full-endoscopic thoracic discectomy and open thoracotomy for myelopathic thoracic disc herniations regardless of radiological severity.

Objective

The radiological severity of thoracic disc herniation (TDH) has been an important factor in determining surgical strategy, especially in centrally located, calcified, or giant lesions. However, it is unclear whether radiological severity alone indicates an open transthoracic approach in myelopathic TDH. In this study, authors compared outcomes between transthoracic surgery and transforaminal endoscopic thoracic discectomy (TETD) and determined whether radiological severity is associated with the surgical approach selection.

Methods

The records of consecutive patients who underwent open transthoracic surgery or TETD for symptomatic TDH between 2007 and 2025 were retrospectively reviewed. Only the patients with myelopathy due to isolated 1- or 2-level TDH were included after applying strict inclusion and exclusion criteria. Demographic, radiological, clinical, and perioperative variables were analyzed. Radiological TDH severity parameters included canal occupying ratio, disc calcification, subarachnoid space effacement grade, and intramedullary T2 high signal intensity. Neurological recovery was assessed according to changes in the modified Japanese Orthopaedic Association scale and visual analog scale scores. Multivariable logistic regression analysis was performed to determine whether imaging variables independently predicted selection of the surgical approach.

Results

A total of 24 patients were included, 14 in the TETD group and 10 in the transthoracic group. Radiological TDH severity parameters did not significantly differ between groups. Neurological recovery was comparable between approaches, whereas pain improvement was greater in the TETD group. Perioperative morbidity was significantly higher in the transthoracic group, including thoracic cavity-related complications (50% vs 0%) and dural tears (70% vs 0%). The transthoracic approach was also associated with a longer operative time and hospital stay. Multivariable analysis showed that none of the radiological variables was associated with selection of the surgical approach.

Conclusions

Radiological TDH severity did not differ between the 2 groups and was not associated with the choice of surgical approach. Neurological outcomes were comparable between the groups, while perioperative morbidity was higher in the transthoracic group. These findings suggest that radiological severity alone may not be enough to determine the surgical approach in TDH and that TETD may be considered in carefully selected patients with myelopathic TDH when adequate decompression is achievable.