Comparative Effectiveness and Safety of Unilateral Hemilaminectomy, Unilateral Biportal Endoscopic Decompression, and Percutaneous Transforaminal Endoscopic Surgery for Lumbar Degenerative Disease: A Systematic Review and Meta-Analysis with Pathology-Stratified Exploratory Subgroup Analyses.

Abstract

BACKGROUND: Three minimally invasive lumbar decompression strategies-unilateral hemilaminectomy (UH), unilateral biportal endoscopic decompression (UBE), and percutaneous transforaminal endoscopic surgery (PTES)-are widely used for lumbar degenerative disease, but pathology-stratified comparative evidence remains limited. OBJECTIVES: To compare clinical efficacy, perioperative efficiency, and safety of UH, UBE, and PTES, and to explore whether comparative effect estimates vary by pathology subtype. METHODS: PRISMA 2020 meta-analysis (PROSPERO CRD420261379841). Six databases (2020-2024) were screened for prospective comparative studies (≥30 patients/arm; ≥6-month follow-up). Risk of bias was assessed using RoB 2, NOS, and ROBINS-I. Random-effects REML models with Hartung-Knapp adjustment were applied; three-arm trials were handled per Cochrane §23.1. MCIDs were pre-specified (ODI=10; VAS-leg=1.5; VAS-back=2). Subgroup analyses were exploratory. RESULTS: Twenty-two studies (8 RCTs, 14 cohorts; N = 3362) were included. UBE and PTES were associated with statistically significant, below-MCID reductions in 12-month ODI versus UH (UBE: MD -5.8, 95% CI -8.1 to -3.5; PTES: MD -3.2, 95% CI -5.4 to -1.0). Exploratory pathology-stratified analyses suggested between-stratum variation in point estimates. Endoscopic techniques reduced overall complications (RR = 0.62, 95% CI: 0.46-0.83), PTES dural tear (RR = 0.43, 95% CI: 0.27-0.69), and reoperation (RR = 0.55, 95% CI: 0.40-0.76). GRADE certainty ranged from moderate to high. CONCLUSIONS: Pooled ODI differences remained below MCID thresholds and do not support strong recommendations for technique selection. Exploratory pathology-related signals require confirmation in adequately powered randomized trials. Observed differences in perioperative efficiency and complication profiles may nevertheless contribute to multidisciplinary surgical planning and individualized anatomical decision-making in selected patients with lumbar degenerative disease during clinical practice.