Thoracic endoscopic spine surgery: systematic review of the literature and exploring the margin of benefit.

BACKGROUND

Thoracic disc herniations are rare and challenging to treat surgically due to their complex regional anatomy, and conventional open approaches are associated with considerable morbidity. While full endoscopic approaches have demonstrated success in the cervical and lumbar spine, their role in the thoracic spine is not as well defined. We performed a systematic review of the literature on full endoscopic surgery for thoracic disc herniations in order to elucidate its safety, efficacy, and potential benefit over conventional open approaches.

METHODS

The PubMed, Web of Science, and Embase databases were queried from inception to February 2026. Studies describing endoscopic approaches to thoracic disc herniations in at least 5 adult patients with reported postoperative outcomes were included. Exclusion criteria included exclusive reporting of open/thoracoscopic approaches, cadaveric studies, and non-English studies. Data on patient characteristics, operative variables, and perioperative outcomes were extracted.

RESULTS

Our systematic review included 23 articles with 695 patients, of which 586 (84.3%) underwent endoscopic surgery and 109 (15.7%) underwent traditional open surgery. In the endoscopic cohort, the most common indication for surgery was radiculopathy (44.2%), followed by myelopathy (43.7%); and myelopathy (70.6%) in the open cohort. Several calcified or partially calcified discs were treated in both the endoscopic and open cohorts (29.8% vs. 36.4%). Endoscopic approaches were associated with shorter operative time (82.3 vs. 201.4 minutes), lower blood loss (18.8 vs. 355.1 mL), reduced fusion rates (1.4% vs. 94.1%), shorter length of stay (2.65 vs. 10.5 days), and lower cost ($7,625.7 vs. $21,055) compared to open approaches. Readmission (3.3% vs. 9.2%), reoperation (3.7% vs. 5.5%), and disc recurrence rates (2.2% vs. 0%) were comparable between cohorts, as were pain and functional outcomes.

CONCLUSIONS

Full endoscopic approaches to thoracic disc herniations are safe and effective alternatives to traditional open approaches in carefully selected patients, offering meaningful advantages with comparable postoperative outcomes. High quality, direct comparative, multicenter studies are needed to better define their margin of benefit.