Beyond the Microscope: Is Endoscopic Discectomy the Next Gold Standard for Lumbar Disc Herniation?

Objective: This systematic review and meta-analysis aimed to compare endoscopic discectomy (ED) with microdiscectomy (MD) for lumbar disc herniation, evaluating patient-reported outcomes, perioperative parameters, and complications to determine if ED could replace MD as the gold standard.Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, we searched PubMed, Embase, Scopus, and Web of Science (January 2000–June 2025) for randomized controlled trials (RCTs) and prospective cohort studies comparing MD with ED subtypes (transforaminal endoscopic lumbar discectomy [TELD], interlaminar endoscopic lumbar discectomy [IELD], and unilateral biportal endoscopy [UBE]). Outcomes included Oswestry Disability Index (ODI), visual analogue scale (VAS) for pain, operative time, hospital stay, complications, and recurrence. Pooled mean differences and odds ratios (ORs) were calculated using random-effects models, with subgroup analyses by ED subtype. Risk of bias was assessed using RoB 2.0 and ROBINS-I tools.Results: Seventeen studies (9 RCTs, 8 cohorts; n=3,115) were included. ED significantly reduced hospital stay (mean difference, -2.43 days; 95% CI, -3.62 to -1.23; p<0.05) and showed greater short-term ODI improvement (mean difference, 2.13; 95% CI, 0.58–3.67). No differences were observed in operative time, long-term ODI, or VAS scores. ED had lower wound complications but a higher recurrence risk with TELD (OR, ~2.0). High heterogeneity (I²>95%) and limited long-term data (>2 years) were noted.Conclusion: ED offers perioperative advantages and comparable efficacy but does not surpass MD due to TELD’s increased recurrence risk. IELD and UBE are promising alternatives, but MD remains the benchmark. Long-term RCTs are needed.