Endoscopic Lumbar Surgery in the Elderly: An Age-Stratified Systematic Review and Meta-Analysis

Systematic review and meta-analysis. To evaluate the safety and clinical effectiveness of endoscopic spinal surgery (ESS) for degenerative lumbar disease in very elderly patients, comparing outcomes in patients aged <80 versus &#x2265;80 years, and summarizing age-stratified symptom and disability changes. Endoscopic spinal surgery (ESS) has gained adoption as a minimally invasive alternative to conventional lumbar decompression for degenerative lumbar pathology. However, its safety and effectiveness in very elderly patients remain uncertain, and age is often treated as a relative contraindication despite limited comparative evidence. We systematically searched PubMed, Scopus, Web of Science, and CENTRAL from inception to October 2025 for observational studies evaluating ESS for lumbar disc herniation, lumbar spinal stenosis, or degenerative lumbar pathology with age-stratified outcomes. Eligible studies reported Visual Analog Scale (VAS) leg and/or back pain, Oswestry Disability Index (ODI), Modified Macnab criteria, or complications. Comparative random-effects meta-analyses were performed for patients aged <80 versus &#x2265;80 years. Single-arm meta-analyses summarized mean changes in pain and disability across the <70 and &#x2265;70-year strata. Nineteen studies (14 retrospective cohorts, 3 prospective cohorts, 2 case series; 5753 patients) published between 2014 and 2025 were included. ESS was predominantly performed for lumbar spinal stenosis (11 studies) and disc herniation (7 studies), with follow-up ranging from 3 to 120 months. In pairwise analyses, patients &#x2265;80 years achieved improvements in VAS leg pain, VAS back pain, ODI, and Modified Macnab success that were comparable to those <80 years, with no significant excess in complications. Single-arm pooling demonstrated large, clinically meaningful reductions in pain and disability in both the <70- and &#x2265;70-year groups, without significant between-group differences. Endoscopic spinal surgery (ESS) provides substantial and comparable symptom relief and functional improvement across age strata, supporting its use in carefully selected elderly and very elderly patients. Chronological age alone should not contraindicate ESS; future prospective, age-focused comparative studies are warranted.