Percutaneous Endoscopic Decompression versus Non-Operative Care for Radicular Pain in the Oldest-Old with Lumbar Stenosis: A Target Trial Emulation Focusing on Pain Relief and Deprescribing

Objective: To emulate a target trial comparing percutaneous transforaminal endoscopic decompression (PTED) versus non-operative care for older patients with unilateral radicular pain due to lumbar spinal stenosis (LSS), focusing on comprehensive treatment failure and deprescribing. Design: Retrospective cohort study using a Target Trial Emulation Framework. Setting: Single academic spine center. Participants: 143 consecutive patients aged ≥ 80 years with unilateral radicular symptoms and imaging-confirmed LSS (February 2022–October 2024). All underwent confirmatory diagnostic nerve root block. Interventions: PTED under local anesthesia (n=75) versus structured non-operative care (n=68). Main Outcome Measures: Primary outcome was 90-day comprehensive treatment failure (unplanned rehospitalization or treatment escalation due to uncontrolled pain or serious complication). Secondary outcomes were Oswestry Disability Index (ODI) and polypharmacy at 12 months. Results: PTED group had significantly lower primary outcome incidence (16.0% vs 44.1%). After multivariable adjustment and inverse probability weighting, PTED was associated with markedly lower odds of comprehensive treatment failure (adjusted odds ratio aOR 0.18, 95% CI 0.07– 0.47), primarily driven by pain-related failure (aOR 0.06; number needed to treat = 3.7). Complication-related failure did not differ significantly between groups, yielding a favorable benefit-risk ratio of 6.6:1. Subgroup analyses confirmed treatment effect consistency across key patient characteristics. At 12 months, PTED patients demonstrated greater ODI improvement (adjusted difference – 8.92 points) and significantly lower polypharmacy prevalence (aOR 0.14), indicating sustained “deprescribing” benefit. Conclusion: In this emulated target trial, PTED was associated with reduced 90-day treatment failure and benefits at 12 months in pain relief and polypharmacy reduction among carefully selected oldest-old patients with LSS. These findings support PTED’s potential in this population and justify the need for a prospective randomized trial. Keywords: percutaneous transforaminal endoscopic decompression, lumbar spinal stenosis, oldest-old, target trial emulation, comprehensive treatment failure, polypharmacy