Comparison of recurrence and postoperative outcomes after endoscopic versus microsurgical sequestrectomy for lumbar...

Endoscopic spinal surgery has expanded beyond standard lumbar procedures to include increasingly complex interventions. Nevertheless, limitations remain, particularly regarding recurrence after lumbar disc surgery. While percutaneous endoscopic and open microsurgical techniques are widely performed, evidence comparing recurrence rates and influencing factors between both approaches remains limited and controversial. This study aimed to compare recurrence rates, perioperative outcomes, and factors associated with recurrence between percutaneous endoscopic sequestrectomy (PES) and open microsurgical sequestrectomy (OMS) in patients undergoing surgery for lumbar disc herniation at follow-up.

A retrospective analysis was performed of 187 consecutive patients treated for lumbar disc herniation (LDH) between September 2019 and November 2022 (PES: n=47; OMS: n=140). OMS was performed via laminotomy or hemilaminectomy; PES was performed via transforaminal percutaneous endoscopic sequestrectomy (TPES) or interlaminar percutaneous endoscopic sequestrectomy (IPES) access according to case-specific considerations. Recurrence was defined as a new ipsilateral LDH at the same level after initial postoperative relief; all recurrences requiring surgery were classified as recurrence requiring reoperation (RrR). Baseline clinical variables, operative time, intraoperative events, length of stay, complications, and recurrence-related reoperations were collected.

Patients in the PES group were younger [47.15±14.12 vs. 53.03±14.31 years; mean difference (MD) -5.88, 95% confidence interval (CI): -10.63 to -1.13; P=0.02] and more often had symptom duration <3 months [95.7% vs. 80.7%; risk difference (RD) 15.0%, 95% CI: -0.6 to 25.4; P=0.01]. Postoperative symptom reduction was high in both groups but slightly lower after PES (93.6% vs. 99.3%; RD -5.7%, 95% CI: -17.0 to 1.7; P=0.050). Operative time was significantly shorter in PES (84.74±37.16 vs. 122.89±41.39 minutes; MD -38.15, 95% CI: -50.97 to -25.33; P<0.001), whereas length of stay was comparable (4.34±1.88 vs. 4.65±2.02 days; MD -0.31, 95% CI: -0.95 to 0.33; P=0.34). Overall complication rates did not differ significantly (21.3% vs. 12.1%; RD 9.1%, 95% CI: -6.6 to 27.2; P=0.15). Recurrence rates were numerically higher after PES (12.8% vs. 7.1%; RD 5.6%, 95% CI: -6.7 to 21.2; P=0.24), and all RrR. Neuropathic pain was more frequent after PES (8.5% vs. 1.4%; RD 7.1%, 95% CI: -1.7 to 19.5; P=0.04). Kaplan-Meier analysis showed no significant difference in recurrence-free survival between PES and OMS (log-rank χ²=1.36, P=0.24). In exploratory multivariable Cox regression, PES was associated with a numerically higher but statistically nonsignificant hazard of recurrence [hazard ratio (HR) 1.98, 95% CI: 0.65-5.98; P=0.23]. Follow-up duration was comparable (51.02±7.63 vs. 50.35±11.06 months; P=0.65).

PES and OMS achieved high clinical improvement with comparable overall complication and recurrence rates at ≥2.5 years. PES was associated with significantly shorter operative time but a higher rate of neuropathic pain. Careful patient selection remains essential, and prospective studies with standardized patient-reported outcomes are warranted.