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Purpose Non-small cell lung cancer (NSCLC) constitutes a substantial global health challenge, with surgical resection serving as a principal therapeutic approach. Nevertheless, the frequency of exploratory thoracotomy without en-bloc resection remains significant, particularly in advanced-stage cases, thereby adversely affecting prognosis. This study aims to predict risk scores for exploratory thoracotomy and analyze postoperative survival in patients with central NSCLC, utilizing CT (computed tomography) imaging subsequent to neoadjuvant therapy. Methods Clinical and radiological data of central NSCLC patients who underwent R0 resection or exploratory thoracotomy from January 2017 to June 2023 were retrospectively reviewed. Independent risk factors for exploratory thoracotomy were identified through a multivariate regression analysis. Subsequently, a nomogram model was developed to assess the risk of exploratory thoracotomy, and was validated through internal and external cohorts. Postoperative disease-free survival (DFS) and overall survival (OS) were analyzed using a Cox regression model. Results A total of 78 who underwent R0 resection following neoadjuvant therapy and 32 patients who underwent exploratory thoracotomy were included in the analysis. The nomogram model derived from tumor area and vascular deformation both identified as independent risk factors for exploratory thoracotomy, exhibited robust predictive performance. Furthermore, a tumor area of less than 250 mm² at the critical CT slice was associated with better DFS and OS following neoadjuvant therapy and R0 resection. Postoperative immunotherapy has the potential to extend survival in cases where exploratory thoracotomy was performed. Conclusion CT imaging at the critical slice post-neoadjuvant therapy is crucial for predicting the risk of exploratory thoracotomy and postoperative survival in patients with central NSCLC.