Meta-Analysis of Complications in Minimally Invasive Spine Surgery (2013–2024)

Study Design. Systematic review and proportional meta-analysis. Objective. To assess total and specific complication rates associated with lumbar biportal endoscopic spine surgery (BESS). Summary of Background Data. In recent years, BESS has emerged as an effective minimally invasive technique for treating lumbar spine conditions, offering benefits such as reduced tissue damage and improved outcomes. However, the safety of BESS across lumbar pathologies is underexplored, with complication rates reported up to 50%. Methods. We registered on PROSPERO (CRD42024570377) and systematically searched PubMed, Medline, Embase, and Cochrane Library (Jan 2013–Mar 2024) per PRISMA guidelines. Studies were included if they focused on lumbar BESS in cohorts of at least 10 adult patients and provided extractable complication data. We excluded conference abstracts, reviews, meta-analyses, non-English studies, and those using microendoscopic, lateral, or oblique approaches. A random-effects model was used to pool complication rates, and study quality was assessed using the Cochrane Risk of Bias Tool and Newcastle-Ottawa Scale. Analyses were performed in R Studio. Results. Seventy-five studies with 4,404 patients (sample sizes 10–797) were included. Most studies were retrospective and geographically concentrated in China and Korea. Patients ranged from 27.6 to 80 years old, with 51.8% being male, and follow-up durations spanned from 3 to 27.5 months. The overall pooled complication rate for lumbar BESS was 7.75% (95% CI [5.97%, 10.01%]). Specific complication rates included dural tears (2.64%), nerve palsies (1.33%), postoperative hematomas (1.80%), surgical site infections (0.20%), and surgical revisions (1.68%). Total complication rates showed significant heterogeneity (I²=82.0%, P <0.01), while specific complications exhibited low to moderate heterogeneity. Conclusions. Lumbar BESS has a low overall complication rate of 7.75%, with dural tears and nerve palsies being the most common. Results should be interpreted with caution due to significant heterogeneity. Future research should explore risk factors of specific complication types and compare long-term outcomes with traditional methods.