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.