Complications in Thoracic Minimally Invasive Spine Surgery in the last Decade: A Proportional Meta-Analysis of Tubular, Uniportal, and Biportal Approaches

Introduction: Minimally invasive spine surgery (MISS) is increasingly used for treating thoracic spinal pathologies due to reduced tissue trauma and faster recovery. However, complication rates vary widely (0% to 43%), and differences between techniques—tubular, uniportal, and biportal approaches—remain unclear. This proportional meta-analysis quantifies thoracic MISS complication rates and assesses the safety profiles of these techniques.

Methods: Following PRISMA guidelines, we conducted a systematic review and meta-analysis (PROSPERO CRD42024594316). PubMed, Medline, Embase, and Cochrane Library were searched (Jan 2013–Mar 2024) for thoracic MISS studies using tubular, uniportal, or biportal approaches. Studies reporting complication rates in adult cohorts were included. Exclusions included non-English articles, reviews, abstracts, and use of microendoscopic, lateral, or oblique techniques. Quality was assessed via the Newcastle-Ottawa Scale. A random-effects model and subgroup analyses were applied, with heterogeneity evaluated using the I² statistic. All analyses were done on RStudio.

Results: Nine studies, comprising 234 patients, were included. All studies had low bias risk. Patient ages ranged from 49.9 to 64.0 years, with 59.7% female. The pooled overall complication rate for was 6.76% (95% CI [2.38%, 17.71%]) with moderate heterogeneity (I² = 35.8%). Subgroup analysis revealed a 3.46% (95% CI [1.08%, 10.51%]) complication rate for tubular (six studies), 16.28% (95% CI [9.88%, 25.63%]) for uniportal (two studies), and 42.86% (95% CI [20.65%, 68.37%]) for biportal (one study) approaches. Common complications included nerve palsies (3.01%, 95% CI [0.59%, 13.87%]), CSF leaks (2.64%, 95% CI [0.79%, 8.43%]), and dural tears (1.25%, 95% CI [0.31%, 4.86%]). Revision surgeries occurred in 1.30% of cases (95% CI [0.33%, 5.04%]).

Conclusion : Thoracic MISS shows a low overall complication rate, with tubular having the lowest risk compared to uniportal and biportal techniques. However, comparisons should be cautious due to limited studies. Larger comparative studies are needed to better define safety and improve outcomes.