Percutaneous transforaminal endoscopic discectomy versus open surgery for cauda equina syndrome: a propensity-matched analysis

Giant lumbar disc herniation causing cauda equina syndrome (CES) is a surgical emergency. While open discectomy (OD) is standard, percutaneous transforaminal endoscopic discectomy (PTED) offers a minimally invasive alternative. High-quality evidence comparing their long-term perineal functional outcomes in this specific context is lacking. To compare the long-term perineal functional recovery between PTED and OD for giant lumbar disc herniation inducing CES using propensity score matching (PSM). A dual-center retrospective cohort study included patients with CES secondary to giant herniation (> 50% canal occupancy). Patients underwent either PTED or OD. PSM (1:1) was performed to balance baseline characteristics (age, BMI, symptom duration, preoperative deficits). Primary outcomes were long-term (> 2 years) bladder and bowel function, assessed via the Urinary Symptom Profile (USP) and Neurogenic Bowel Dysfunction (NBD) scores, and saddle sensation. Poor recovery was defined as USP ≥ 1 or NBD ≥ 3. After PSM, 30 matched pairs ( n = 60) were analyzed. Baseline characteristics were well-balanced. Perioperatively, PTED resulted in significantly less blood loss (10 vs. 50 mL, p < 0.001) and shorter hospital stay (3.7 vs. 5.4 days, p < 0.001), but longer operative time (80 vs. 68 min, p < 0.001). At a median follow-up of ~ 48 months, there were no significant differences in residual rates of stress urinary incontinence, overactive bladder, low urinary flow, defecation difficulty, or fecal incontinence (all p > 0.05). The rate of poor overall recovery (PTED 30.0% vs. OD 36.7%, p = 0.584) was comparable. Saddle sensory deficit was less frequent in the PTED group (10.0% vs. 33.3%), but this difference was not significant after adjustment for radiculopathy laterality (aOR 0.27, p = 0.104), although the direction favored PTED. PTED yields sphincter recovery equivalent to OD and offers better perioperative outcomes. The reduction in saddle deficit seen with PTED was attenuated after laterality adjustment but remained directionally favorable. PTED is therefore a valid minimally invasive option for selected CES patients, particularly unilateral cases.