Comparative Efficacy and Safety of Minimally Invasive, Full-Endoscopic, and Biportal Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Diseases: A Network Meta-Analysis.

Abstract

Study DesignNetwork Meta-analysis.ObjectiveTo evaluate the clinical efficacy and safety of minimally invasive (MIS-), full endoscopic (FE-), and biportal endoscopic (BE-) transforaminal lumbar interbody fusion (TLIF).MethodsPubMed, Embase, Cochrane Library, and ClinicalTrials.gov registry were searched up to August 2025. Randomized controlled trials and nonrandomized studies of intervention comparing MIS-TLIF, FE-TLIF, and BE-TLIF for lumbar degenerative diseases were included. Network meta-analysis was conducted using the frequentist framework, with meta-regressions assessing effect modifiers.Results49 studies (4188 patients) were included. FE-TLIF and BE-TLIF significantly reduced back pain vs MIS-TLIF from 1 month postoperatively through final follow-up. However, leg pain showed no significant differences among the three approaches. FE-TLIF and BE-TLIF demonstrated superior short- and mid-term functional outcomes, with FE-TLIF achieving the shortest hospital stay. Both endoscopic techniques reduced blood loss compared to MIS-TLIF. Long-term functional improvement, fusion rates, and complication rates were comparable, though FE-TLIF and BE-TLIF required longer operative times. Meta-regression suggested greater back pain relief in older patients following FE-TLIF.ConclusionBE-TLIF and FE-TLIF are safe techniques offering advantages over MIS-TLIF, including greater back pain reduction, improved short-term function, shorter hospital stays, and reduced blood loss. However, both require longer operative times. Meta-regression analysis suggested a promising signal that FE-TLIF may provide greater back pain relief in older patients. MIS-TLIF remains viable for those with higher anesthesia risk or significant cardiopulmonary comorbidities. Further high-quality randomized controlled trials are needed to validate these findings and refine patient selection criteria.