title: Surgical Approaches for the Treatment of Thoracic Disk Herniation: Results of a Decision Analysis.
abstract: METHODS
  A decision analysis.
  
  
  OBJECTIVE
  To perform a decision analysis utilizing postoperative complication data, in conjunction with health-related quality of life (HRQoL) utility scores, to rank order the average health utility associated with various surgical approaches used to treat symptomatic thoracic disk herniation (TDH).
  
  
  BACKGROUND
  Symptomatic TDH is an uncommon entity accounting for <1% of all symptomatic herniated disks. A variety of surgical approaches have been developed for its treatment, which may be classified into 4 major categories: open anterolateral transthoracic, minimally invasive anterolateral thoracoscopic, posterior, and lateral. These treatments have varying risk/benefit profiles, but there is still no set algorithm for choosing an approach in cases with multiple surgical options.
  
  
  METHODS
  We searched Medline, EMBASE, and the Cochrane Library for relevant articles on surgical approaches for TDHs published between 1990 and August 2014. Pooled complication data and HRQoL utility scores associated with each complication were evaluated using standard meta-analytic techniques to determine which surgical approach resulted in the highest average HRQoL.
  
  
  RESULTS
  Posterior surgical approaches resulted in the highest average HRQoL, followed by thoracoscopic, lateral, and finally open anterolateral transthoracic procedures. The higher average HRQoL associated with posterior approaches over all others was highly significant (P<0.001); conversely, the open anterolateral approach resulted in a lower average postoperative utility compared with all other approaches (P<0.001).
  
  
  CONCLUSIONS
  The results of this decision analysis favor posterior over lateral approaches, and thoracoscopic over open anterolateral approaches for the treatment of symptomatic TDHs, which may guide surgeons in cases where multiple surgical options are feasible. Future studies, such as randomized clinical trials, are necessary to ascertain whether novel surgical strategies have risk/benefit profiles that ultimately supersede those of traditional approaches, and whether enough cases are encountered by the average surgeon to justify their adoption.
authors.affiliation: *Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA †Hartford Healthcare Medical Group-Neurosurgery, Hartford, CT.
authors.forename: Nikhil R
authors.initials: NR
authors.lastname: Nayak
authors.forename: Joel A
authors.initials: JA
authors.lastname: Bauman
authors.forename: Sherman C
authors.initials: SC
authors.lastname: Stein
authors.forename: Jayesh P
authors.initials: JP
authors.lastname: Thawani
authors.forename: Neil R
authors.initials: NR
authors.lastname: Malhotra
mesh_terms: D003661:Decision Support Techniques; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology; D011788:Quality of Life; D012086:Reoperation; D013904:Thoracic Vertebrae / Q000601:surgery*; D016896:Treatment Outcome