Endoscopic spine surgery across the pediatric pathological spectrum: A systematic review of indications, techniques, and outcomes

Background: Full endoscopic and biportal endoscopic techniques are well established in adult spine surgery, but their extension to pediatric patients has been described mainly in case reports and small series. No prior systematic review has mapped this literature across the full pediatric spinal pathology spectrum. Methods: PubMed/MEDLINE, Cochrane CENTRAL, and ClinicalTrials.gov were searched for studies of patients aged 18 years or younger undergoing a uniportal (percutaneous endoscopic lumbar discectomy/percutaneous endoscopic interlaminar discectomy (PEID)/percutaneous transforaminal endoscopic discectomy) or biportal (unilateral biportal endoscopy) endoscopic spinal procedure for any pathology. Of 980 records screened independently by two reviewers, 58 underwent full-text review. Risk of bias was assessed with Risk of Bias in Nonrandomised Studies of Interventions (ROBINS-I) and Joanna Briggs Institute (JBI) checklists. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 and was registered on the Prospective Register of Systematic Reviews (CRD420261448214). Results: Twenty-six studies (1,023 patients, 2001–2026) were included; no randomized trial was identified. Twenty-one studies (1,018 patients) addressed lumbar disc herniation, with modified MacNab excellent/good outcomes of 87–100% and reoperation/recurrence rates of 0–12.5%, highest in the longest-follow-up study. Single case reports addressed pars-fracture repair, tethered cord release, two bone-lesion tumor excisions, and infectious spondylodiscitis debridement; no study addressed congenital spinal deformity or tumor resection. All eight comparative cohort studies were rated Serious risk of bias by ROBINS-I; the eighteen case series and case reports were well documented but weak on consecutive enrollment. Conclusion: Endoscopic techniques are increasingly used in pediatric spine surgery, but the evidence base outside lumbar disc herniation remains limited to single case reports, and no study addressed congenital deformity. Multi-institutional registries, pediatric-specific outcome measures, and prospective comparative studies are needed before broader adoption can be recommended.