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=3,362) 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.
Ramon-Cuellar et al. (2026) studied this question.