Endoscopic Spine Surgery vs. Conventional Approaches for Lumbar Spondylolisthesis: Systematic Review and Meta-Analysis

Background/Objectives: To determine whether ESS provides superior clinical, radiologic, or perioperative outcomes compared with non-ESS surgical strategies in lumbar spondylolisthesis. Methods: We conducted a PRISMA-guided systematic review and meta-analysis comparing ESS with non-ESS strategies specifically for lumbar spondylolisthesis. PubMed, Web of Science, Scopus, and CENTRAL were searched from inception to December 2025, plus reference-list screening. Primary outcomes were mean change in VAS back pain, VAS leg pain, and Oswestry Disability Index (ODI); secondary outcomes included radiologic measures (disc height, lumbar lordosis angle, fusion rate) and perioperative outcomes (blood loss, operative time, length of stay, complications). Results: Eighteen studies (16 retrospective cohorts, 1 RCT, 1 case–control) involving 1200 patients with lumbar spondylolisthesis (2019–2025) were included. ESS showed no significant differences versus non-ESS in mean change in VAS back pain (13 studies; MD −0.07), VAS leg pain (14 studies; MD 0.08), or ODI (12 studies; MD 0.51). No statistically significant differences were detected in radiological outcomes (disc height, lumbar lordosis angle, and fusion rate). ESS was associated with reduced blood loss (MD −132.98) and shorter hospital stay (MD −2.86 days), with no difference in operative time (MD 3.96) or postoperative complications (RR 0.86). Subgroup analyses compared endoscopic fusion with MIS fusion, open fusion, and non-endoscopic decompression. Endoscopic versus MIS fusion showed lower blood loss (MD: −50.9 mL) and shorter hospital stay (MD: −1.4 days) but longer operative time (MD: +17.2 min), with no differences in clinical outcomes. Comparisons involving decompression and open fusion were limited by the small number of studies and should be considered exploratory. Conclusions: For lumbar spondylolisthesis, no statistically significant differences were detected between ESS and non-endoscopic approaches in pain, disability, radiologic outcomes, or complication rates, with potential perioperative advantages in blood loss and length of stay. However, these findings should be interpreted cautiously because the available evidence is predominantly retrospective, procedurally heterogeneous, and affected by substantial variation in follow-up duration.