Primary spontaneous pneumothorax: reassessing the role of chest CT in surgical decision-making

Primary spontaneous pneumothorax (PSP) is a common condition managed either conservatively or surgically. This study investigated whether specific chest X-ray or computed tomography (CT) characteristics can predict the need for surgical intervention and clarified the role of each imaging modality in surgical planning.

We retrospectively reviewed records of all PSP patients at a university hospital from 2013 to 2024. Only patients with available imaging were included in the analysis. Radiographic characteristics, clinical data, and outcomes were collected. Univariate analysis and logistic regression were performed to identify predictors of surgical intervention.

Ninety-one patients were included, with 35 (38.5%) undergoing surgical intervention. Chest X-ray findings did not significantly correlate with surgical decisions (odds ratio (OR) = 0.920, 95% confidence interval (CI) 0.239-3.533, P = 0.903). Patients with recurrent pneumothorax were more likely to require surgery (74.3% vs. 25.7%, P < 0.0001). Logistic regression revealed that symptom onset 1 day prior to admission increased the likelihood of surgery 4.122-fold compared to same-day onset (95% CI 1.004-19.920, P = 0.049). Eighteen patients underwent CT scanning, and their chest X-ray findings closely correlated with CT findings (kappa's score = 0.944, 95% CI 0.83-1.00).

Chest X-ray findings alone are insufficient predictors of surgical intervention in PSP. Instead, prolonged symptom duration and a history of recurrence are key determinants of surgical need. The strong correlation between X-ray and CT findings suggests that routine preoperative CT may add little value, particularly in young patients. Further prospective studies are needed to validate these results.

The online version contains supplementary material available at 10.1007/s12055-025-02014-6.