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OBJECTIVE: Defining indication for intervention in substernal goiter, and secondarily define when thoracic intervention may be required. DATA SOURCES: PubMed, Scopus, CINAHL. METHODS: A systematic review and meta-analysis were performed on studies employing thyroidectomy for substernal goiters. Meta-analysis of continuous measures, proportions, and comparison of weighted proportions was performed for patient characteristics, symptoms, and outcomes. RESULTS: Data from 102 studies were included, with a total study population of 15,719 patients undergoing substernal thyroidectomies. Criteria for classifying substernal goiter were heterogeneous across studies, with a plurality (21/102) defining diagnosis by > 50% of the goiter mass located below the thoracic inlet. There was a female predominance at 67% (CI 64.2-69.9) with a mean age of 58 years old (10-94). Most common preoperative symptoms were a described "neck mass" (71.1%, CI 57.6-82.9) and overall compressive symptoms (64.8%, CI 52.4-76.2). 27.6% (CI 22.4-33.1) of the population remained asymptomatic. On radiologic imaging, tracheal deviation and compression were identified in 60.6% (CI 52.5-68.5) and 48.6% (CI 37.6-59.6) of the population, respectively. Cervical approach alone was performed in 88.7% (CI 86.0-91.1) of the population, while 10.4% (CI 8.2-12.8) required additional thoracic intervention. Malignancy was moderate and seen in 12.4% (CI 10.4-14.6) of cases. CONCLUSION: Results highlight the indication for substernal surgery is largely due to the presence of clinical symptoms or compressive findings on imaging; however, over a quarter of the population is asymptomatic and over 50% are without compressive findings on imaging. When surgery is undertaken, a cervical approach is often adequate, suggesting that only a minority of the population may require thoracic intervention.