Symptomatic Thoracic Disc Herniations: Is an Open or Endoscopic Approach Best

Introduction: Thoracic disc herniations cause myelopathy or radiculopathy, requiring decompression. Open thoracic discectomy often requires transpedicular decompression and fusion with extensive hospital stays. The advent of endoscopic thoracic discectomy offers a less invasive alternative, however, comparative costs, resource utilization, and outcomes for endoscopic versus open thoracic discectomy is unknown.

Methods: A single-center, retrospective, cohort study using prospectively collected data of patients undergoing one-level thoracic discectomy was undertaken between 2018-2023. Initial surgical cost was defined as the total cost-of-care for the initial surgery and hospital stay.

Results: 18 open and 12 endoscopic thoracic surgeries were performed for symptomatic thoracic discs. Preoperative demographics, symptoms, and radiographic findings were comparable between the cohorts. Open surgery had significantly higher length-of-stay [Mean±95%CI (days)] (4.9±1.4 vs. 0, p< 0.001), operative time [353.5 minutes (IQR 63) vs. 141.5 minutes (IQR 36), p< 0.001], and blood loss [350 mL (IQR 420 mL) vs. 6.5 mL (IQR 20 mL); p< 0.001]. 17 (94%) open patients required fusion versus 0 endoscopic (p < 0.001). 6-week rates of neurological improvement were equivalent. Open surgery was associated with comparable all-cause readmissions [5 (31%) vs. 2 (17%), p=.669] and reoperations [1 (6%) vs. 2 (17%), p=0.548]. Open surgical costs were 7x higher ($60,571, IQR $17,782) vs. endoscopic [$8,128, IQR $1,848); p< 0.001] driven by length-of-stay (β=$2,073/night, p=0.007), operative time (β=$100/minute, p= < 0.001), and open surgery (β=$18,556, p=0.004) on multivariable analysis. On sensitivity analysis, open repair was never cost-efficient against endoscopic repair and endoscopic revision rates of 87% were required for break-even cost.

Conclusion : Endoscopic thoracic discectomy was associated with significantly decreased costs compared to open surgery, with significantly decreased LOS, operative time, and blood loss, and with similar neurological outcomes, readmissions, and reoperations. These findings may help patients and surgeons seek endoscopic thoracic discectomy as a less morbid surgical alternative when appropriate.