Anterior versus posterior approaches in thoracic discectomies: an updated systematic review and meta-analysis

Thoracic discectomy is performed via anterior or posterior approaches through different techniques. An updated comparison incorporating recent research is needed to inform clinical decision-making and guide future studies. A comprehensive search identified relevant studies, and meta-analyses evaluated neurological outcomes, complications, reoperations, and surgical efficiency metrics, including estimated blood loss (EBL) and length of stay (LOS). We pooled 37 studies (34 retrospective, 1 trial and 2 prospective) amounting to 27,450 patients. No significant differences were observed between anterior and posterior approaches for neurological improvement (OR 1.47, 95% CI 0.8-2.72), neurological 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), CSF leakage (OR 1.54, 95% CI 0.24-9.99), or postoperative neuropathic pain (OR 0.67, 95% CI 0.10-4.35). Operative time was similar (SMD 5.42, 95% CI -0.46 to 11.29). Mean EBL was lower for anterior approaches (600.1 mL, 95% CI 246.99-953.23) compared to posterior approaches (1925.1 mL, 95% CI 837.32-3012.88). The posterior approach had fewer overall complications (OR 0.32, 95% CI 0.24-0.42) and shorter LOS (SMD 0.48, 95% CI 0.25-0.71). Subgroup analysis confirmed that open approaches in both groups resulted in fewer complications and higher rates of neurological improvement. The choice of anterior vs. posterior approach for thoracic discectomy depends on patient factors and surgeon preference. Anterior approaches may provide better neurological outcomes but with potentially higher complication rates. Further research is needed to identify the optimal approach for each patient.