Anterior versus posterior approaches for thoracic disc herniation: Association with postoperative complications

Thoracic disc herniations (TDH) represent 1.5-4% of all intervertebral disc herniations. Surgical treatment can be divided into anterior, lateral and posterior approaches and is an area of contention in the literature. Available evidence consists mostly of single-arm, single-institutional studies with limited sample sizes. The objective of this study is to investigate 30-day surgical outcomes following excision of TDH utilizing a national surgical registry.

The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) was queried for cases that underwent anterior (thoracotomy or thoracoscopy), lateral (extracavitary or costotransversectomy) or posterior (transpedicular or laminectomy) surgery for a primary diagnosis of TDH between 2012 and 2015.

A total of 388 patients (48% females) were included in the analysis. An anterior approach was used in 65 patients, lateral approach in 34, transpedicular approach in 90 and laminectomy in 199. Overall, baseline demographics and clinical characteristics were similarly distributed between the four procedure groups. Patients undergoing an anterior approach spent, on average, 2-3 more days in the hospital compared to the other groups (p < .001). Furthermore, they were more likely to have developed a major complication (27%) compared to the lateral (8%), transpedicular (18%) or laminectomy group (14%) (p = .13). Unplanned 30-day readmission and return to the operating room occurred in 5-8% of patients (p = .69 and 0.63, respectively). Lastly, the majority of the patients were discharged to home or a home facility (anterior-74%; lateral-81%; transpedicular-68% and laminectomy-74%, p = .58).

Anterior approaches had longer LOS and higher, although not statistically significant, complication rates. No difference was found with regard to discharge disposition. In light of these findings, surgeons should weigh the risks and benefits of each surgical technique during tailoring of decision making.