Endoscopic Lumbar Decompression in Obese Patients: A Systematic Review of Comparative and BMI-Stratified Evidence
Jacqueline Albert, Jay Chung, Arjun Gupta, Regina Golding, Sachin Mehta, Madison McFarland, Samuel Winski, Vishal Shankar, Manish Bhatta, Kevin Newsome, Gregory Connors, Caroline D. Patton, Pamela Zuckerman, Taikhoom Dahodwala, Matthew Chong, Ananth Eleswarapu, Jonathan Krystal, Mitchell Fourman, Daniel BermanStudy Design:
Systematic review.
Objective:
To evaluate perioperative and clinical outcomes after open
Summary of Background Data:
Obesity is associated with increased technical difficulty and perioperative morbidity in lumbar spine surgery. Endoscopic spine surgery (ESS) may reduce soft tissue disruption and wound morbidity, but comparative data in obese patients remain limited.
Materials and Methods:
A systematic review was performed according to PRISMA guidelines. PubMed, Embase, and Web of Science were searched from inception through January 21, 2026. Studies were included if they enrolled adult patients with obesity undergoing lumbar decompression without fusion for degenerative pathology and reported at least one operative or perioperative outcome. Pediatric patients, nonlumbar or nondegenerative procedures, fusion-only cohorts, and nonprimary literature were excluded. Demographics, operative outcomes, complications, reoperation, and patient-reported outcomes were extracted and synthesized qualitatively.
Results:
Fourteen studies were included after screening 667 titles/abstracts and 93 full texts; 11 primary clinical studies informed the results synthesis. Two studies directly compared endoscopic and open decompression in obese patients. Ma and colleagues reported lower estimated blood loss after unilateral biportal endoscopic decompression compared with open surgery and shorter hospitalization. Castel and colleagues reported shorter hospitalization after full endoscopic lumbar discectomy compared with open surgery, although operative time was longer in the endoscopic cohort. Complications included surgical site infection, durotomy, nerve root injury, and recurrent disc herniation, with low event rates. BMI-stratified studies showed comparable pain and disability improvement between obese and nonobese patients.
Conclusion:
Based on limited comparative evidence from two studies, endoscopic decompression in obese patients was associated with similar clinical improvement and potential perioperative advantages compared with open surgery, including lower reported blood loss and shorter length of stay. Limitations include retrospective designs, heterogeneous techniques, only two comparative studies, and inconsistent reporting. These findings should be considered preliminary, and prospective comparative studies are needed.
Level of Evidence:
Level III.