Endoscopic versus open lumbar decompression: a retrospective cohort study of 31,000 patients with 90-day follow-up.

Endoscopic lumbar decompression has emerged as a minimally invasive alternative to open decompression for degenerative lumbar disease. Although prior work suggests potential recovery benefits, large-scale data comparing safety outcomes remain limited. This study compared 90-day complications, reoperation, and healthcare utilization between endoscopic and open lumbar decompression using a national database. We performed a retrospective cohort study using the TriNetX U.S. Research Network. Adults undergoing lumbar decompression were identified using procedure codes for percutaneous endoscopic decompression or discectomy versus conventional open decompression. Primary outcomes were incidental durotomy, cerebrospinal fluid (CSF) leak or pseudomeningocele, and unplanned reoperation. Secondary outcomes included emergency department revisit, readmission, meningitis, wound disruption, venous thromboembolism, and myocardial infarction. Propensity score matching was performed 1:1 using demographic and clinical covariates. After matching, 31,408 patients were included in each cohort. Rates of incidental durotomy were similar between endoscopic and open decompression (0.4% vs. 0.4%). Endoscopic decompression was associated with lower rates of cerebrospinal fluid leak or pseudomeningocele (0.3% vs. 0.5%) and unplanned reoperation (0.2% vs. 1.8%). Overall, healthcare utilization did not differ significantly between cohorts (6.3% vs. 6.1%). However, meningitis (0.4% vs. 0.2%), deep vein thrombosis (0.7% vs. 0.5%), and myocardial infarction (0.4% vs. 0.2%) occurred more frequently following endoscopic decompression. No significant differences were observed in wound disruption. Endoscopic lumbar decompression was associated with lower 90-day rates of cerebrospinal fluid-related complications and unplanned reoperation, though absolute differences were small. Higher rates of meningitis, venous thromboembolism, and myocardial infarction were observed in the endoscopic cohort, while overall healthcare utilization and wound-related complications were comparable. Overall, endoscopic decompression appears safe with modest advantages over open surgery.Level of evidence: Level III Retrospective Comparative Cohort Study.