Minimally invasive versus open surgery for the management of thoracolumbar spondylodiscitis: a systematic review and meta-analysis of observational studies

Purpose Thoracolumbar spondylodiscitis increasingly affects older patients in whom surgical morbidity strongly influences recovery. Minimally invasive surgery (MIS) aims to achieve debridement, microbial diagnosis, and mechanical stabilization while reducing soft-tissue disruption, but its comparative performance relative to open surgery (OS) remains uncertain. This review evaluated the efficacy and safety of MIS versus OS for thoracolumbar spondylodiscitis. Methods We conducted a systematic review and meta-analysis of comparative retrospective cohort studies. MIS approaches included percutaneous pedicle screw fixation, transforaminal interbody fusion, and endoscopic debridement techniques, compared with conventional open surgical approaches. Electronic searches of PubMed, Embase, and CENTRAL (24th September 2025) were performed. All ten included studies were retrospective comparative cohorts. Random-effects meta-analysis generated pooled mean differences and risk ratios. Heterogeneity, sensitivity analyses, and risk of bias (ROBINS-I) were assessed. Certainty of evidence was evaluated using GRADE. Results Ten retrospective cohorts of 855 adults (MIS 383; OS 472) were included. No randomized controlled trials were identified. MIS was associated with fewer post-operative complications, including halved overall complication risk and reduced surgical-site infections. MIS also demonstrated shorter operative time, reduced intraoperative blood loss and transfusion requirement, lower early post-operative pain, and 3.8-day reduction in hospital stay. Measures of infection control, including culture positivity, early post-operative C-reactive protein levels, and recurrence, showed no statistically detectable difference between MIS and OS, although the observational evidence base precludes causal inference. Certainty of evidence was moderate for overall complications, surgical-site infection, operative time, length of stay, and CRP change; low for blood loss, sepsis, and mortality; and very low for transfusion volume, recurrence, and screw misplacement. Conclusions These findings suggest that MIS was associated with lower peri-operative morbidity and comparable infection-control outcomes, supporting its use as a tissue-sparing surgical option for surgically indicated cases of thoracolumbar spondylodiscitis. Prospective standardized studies are needed to refine patient selection and clarify the role of emerging full endoscopic techniques.