Clinical utility and transparency in randomized trials of biportal endoscopic lumbar discectomy: a systematic review

Unilateral biportal endoscopic discectomy has grown rapidly as a minimally invasive treatment for lumbar disc herniation, supported by an expanding body of randomized controlled trials. However, randomization alone does not guarantee a trial is clinically useful, and no prior study has evaluated whether these trials are designed and reported in a way that supports confident clinical decision-making. The Van't Hooft framework assesses this dimension directly, scoring clinical utility and transparency separately from conventional risk-of-bias tools, addressing a gap left by prior appraisals focused on effect estimates alone.

A systematic review of PubMed, Cochrane Library, and Scopus identified randomized controlled trials evaluating unilateral biportal endoscopic discectomy for lumbar disc herniation. Two reviewers independently screened studies and scored each included trial using the Van't Hooft framework, yielding clinical utility (maximum 14), transparency (maximum 12), and total usefulness (maximum 26) scores. Item-level frequencies and temporal trends by publication year were summarized descriptively and with univariable linear regression.

Four trials (324 patients) met inclusion criteria. Mean clinical utility was 9.5±1.0, mean transparency was 8.5±1.3, and mean total usefulness was 18.0±0.8. Value-for-money reporting and assessor blinding were absent in all four trials. Clinical utility rose nonsignificantly over time (β = 0.519/year, P = 0.222), while transparency declined nonsignificantly (β = -0.815/year, P = 0.053).

Randomized trials of biportal endoscopic discectomy address clinically relevant, patient-centered questions but report transparency inconsistently. Future trials should prioritize preregistration, data sharing, and cost evaluation to strengthen the evidence base guiding this increasingly common procedure.