Comparison between endoscopic lumbar discectomy with and without annulus fibrosus suturing: a systematic review and meta-analysis.

Abstract

Systematic review and meta-analysis. Endoscopic lumbar discectomy is a minimally invasive technique used to treat herniations while reducing tissue trauma, incision length, blood loss, and infection. However, such procedures may damage the annulus fibrosus, which increases the risk of reherniation and revision. The current study aimed to compare the outcomes of endoscopic lumbar discectomy with and without simultaneous repair of the annulus fibrosus through suturing. From project initiation on June 2025 to the present, three reviewers conducted a systematic review of studies published in PubMed, Embase, and Cochrane Library databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All meta-analyses were conducted using STATA ver. 18.0. A total of nine studies, with 1,192 patients who underwent endoscopic lumbar discectomy for lumbar herniation, were included for analysis. Among the included patients, 514 (43.1%) underwent annulus fibrosus suturing, whereas 678 (56.9%) received only discectomy. The most commonly involved disc segment was L4/L5 with 267 patients (44.5%). Patients who underwent endoscopic lumbar discectomy with annulus fibrosus suturing showed a significant increase in operative time by 8.89 minutes (weighted mean difference [WMD], 8.89 minutes; 95% confidence intervals [CI], 1.01-16.77; p=0.03), had 0.31 times the odds of developing reherniation (odds ratio [OR], 0.31; 95% CI, 0.17-0.55; p=0.00), and had 0.26 times the odds of needing revision surgery (OR, 0.26; 95% CI, 0.10-0.68; p=0.01). No significant difference in intraoperative blood loss and hospital length of stay were observed between the groups. Postoperative and 3-month follow-up Visual Analog Scale (VAS)/Oswestry Disability Index (ODI) scores did not significantly differ between the groups at correlation coefficients r=0.3, 0.5, and 0.7, although the suture group demonstrated a favorable trend in ODI scores (p=0.0681-0.0782). Among the patients who underwent lumbar endoscopic discectomy, those who received annulus fibrosus suturing demonstrated significantly increased operative time but decreased reherniation and reoperation rates compared to those who did not received annulus fibrosus suturing. No significant difference in length of stay or blood loss were observed between the two groups. Conflicting results were noted for VAS and ODI scores, with patients receiving annulus fibrosus suturing generally showing better ODI outcomes but worse VAS scores.