Endoscopic Versus Open Lumbar Decompression: A Propensity-Matched National Cohort Study of 50,000 Patients with 90-Day Follow-Up

Introduction: 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. Methods 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, length of stay, discharge disposition, meningitis, wound disruption, venous thromboembolism, and myocardial infarction. Propensity score matching was performed 1:1 using demographic and clinical covariates. Results After matching, 25,242 patients were included in each cohort. Endoscopic decompression demonstrated lower rates of incidental durotomy (0.3% vs 0.5%), CSF leak or pseudomeningocele (0.2% vs 0.5%), and unplanned reoperation (0.1% vs 1.8%). Healthcare utilization (7.2% vs 6.8%) and meningitis (0.4% vs 0.3%) were slightly higher in the endoscopic cohort. No significant differences were seen in wound disruption, venous thromboembolism, or myocardial infarction. Conclusion Endoscopic lumbar decompression was associated with lower 90-day rates of select complications and reoperation, though absolute differences were small. Slightly higher utilization and meningitis rates were observed, but systemic complication rates were comparable. Overall, endoscopic decompression appears safe with modest advantages over open surgery. Level of Evidence Level III Retrospective Comparative Cohort Study