Comparative analysis of clinical outcomes and healthcare costs following endoscopic versus open lumbar discectomy: a multidatabase study utilizing TriNetX, NIS, and NASS.

Objective

Endoscopic lumbar discectomy (ELD) has emerged as a minimally invasive alternative to open lumbar discectomy (OLD), with advantages including reduced tissue disruption and amenability to outpatient settings. Comparative data on clinical outcomes and costs across care settings remain limited. This study leveraged three national databases, TriNetX, National Inpatient Sample (NIS), and Nationwide Ambulatory Surgery Sample (NASS), to analyze short- and long-term outcomes and inflation-adjusted healthcare costs between ELD and OLD.

Methods

A retrospective cohort study was performed using TriNetX, NIS, and NASS. TriNetX cohorts underwent 1:1 propensity score matching on age, sex, race, BMI, and Charlson Comorbidity Index score, yielding 8551 patients per group. Short-term (30 and 90 days) and long-term (6 months and 1, 2, and 5 years) outcomes were compared using risk ratios (RRs). The NIS and NASS were used to compare inflation-adjusted charges in inpatient and outpatient settings, respectively, via multivariable linear regression. A 1:1:1:1 propensity score-matched cross-setting analysis (192 per group) enabled direct charge comparison across all four groups: NIS endoscopic, NIS open, NASS endoscopic, and NASS open. Charges were adjusted to 2022 US dollars.

Results

ELD was associated with significantly lower 30-day rates of emergency department visits (RR 0.61), wound dehiscence (RR 0.52), hematoma (RR 0.39), blood transfusion (RR 0.51), incision and debridement (RR 0.33), and deep surgical site infection (0% vs 0.25%) (all p < 0.001), with differences persisting at 90 days. ELD demonstrated higher additional discectomy rates at 6 months (RR 1.19, p = 0.014), no difference at 1 year, and lower rates at 2 and 5 years (RR 0.74, p < 0.001). Same-level open discectomy and lumbar fusion were significantly lower in the ELD group at all time points through 5 years (fusion: RR 0.63, p < 0.001). Postlaminectomy syndrome rates were equivalent. Inpatient charges did not differ significantly between ELD and OLD ($73,235 and $75,027, respectively; p = 0.091). Outpatient ELD charges were higher than outpatient OLD charges ($44,069 vs $35,276, p < 0.001). On cross-setting comparison, both approaches carried substantially lower outpatient versus inpatient charges (ELD: $42,324 vs $73,030; OLD: $24,452 vs $71,244; p < 0.001).

Conclusions

ELD demonstrates a favorable short-term complication profile and reduced long-term need for lumbar fusion compared to OLD. While outpatient ELD carries higher charges than outpatient OLD, both approaches are substantially more cost-efficient in outpatient versus inpatient settings, supporting the adoption of endoscopic techniques in ambulatory surgical environments.