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

Abstract

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.

INTRODUCTION

Full endoscopic and biportal endoscopic (unilateral biportal endoscopy [UBE]) techniques have become one of the fastest-growing areas of spine surgery over the past decade, and in adult patients, they have accumulated a large and rapidly expanding evidence base. A 2022 systematic review and meta-analysis of 16 studies (1,488 patients) comparing UBE against microendoscopic discectomy (MED), percutaneous endoscopic lumbar discectomy (PELD), and posterior lumbar interbody fusion found UBE superior to MED for early back pain relief, with otherwise comparable pain, disability, and complication outcomes between UBE and both MED and PELD.[36] Two independent 2025 systematic reviews addressing UBE versus uniportal endoscopy for lumbar spinal stenosis reached concordant conclusions: both found shorter operative time with UBE and comparable pain, disability, blood loss, hospital stay, and complication rates between techniques.[10,34] A third 2025 systematic review focused specifically on the learning curve for endoscopic spine surgery across techniques.[3] The density of this adult literature stands in direct contrast to the pediatric literature mapped in this review.

The translation of these techniques to pediatric and adolescent patients has followed a very different trajectory. Pediatric spine surgery differs from adult practice in several respects relevant to endoscopic technique: the underlying pathology mix is different (disc herniation is comparatively rare and often has a stronger genetic, developmental, or traumatic component; degenerative stenosis is essentially absent), anatomical structures are smaller and still growing, anesthesia and radiation-exposure considerations carry greater weight over a longer remaining lifespan, and return to school and sport is a central outcome for young patients and their families.[1] These differences plausibly make minimally invasive, tissue-preserving endoscopic approaches attractive in this population, but adult evidence cannot be assumed to generalize directly.

Two related systematic reviews provide partial coverage of this space. A 2024 systematic review and meta-analysis pooled discectomy outcomes, including percutaneous endoscopic and microendoscopic techniques alongside open and tubular approaches, for pediatric and adolescent lumbar disc herniation, but was not restricted to endoscopic technique and noted that the absence of randomized trials prevented direct comparative analysis.[27] A 2026 systematic review of endoscopic and percutaneous minimally invasive pars interarticularis repair identified a pooled cohort dominated by young adults and athletes, without a dedicated pediatric or adolescent study arm.[22] A background epidemiological study of pediatric lumbosacral disc herniation risk factors and surgical outcomes (nonendoscopic microdiscectomy cohort) further illustrates that most published pediatric disc herniation literature does not use endoscopic technique at all.[25] A 2022 narrative overview of pediatric applications of endoscopic spine surgery summarized several relevant case reports but did not use systematic review methodology, a reproducible search strategy, or formal data extraction.[1]

To our knowledge, no prior systematic review has mapped the full breadth of endoscopic spine surgery applications across pediatric spinal pathology using a documented, reproducible screening process. The objective of this review was to systematically identify, screen, and narratively synthesize the published evidence on endoscopic spine surgery in pediatric and adolescent patients across all reported indications and to explicitly map where evidence exists, where it is thin, and where it is entirely absent.

MATERIALS AND METHODS

Protocol and registration

This review was conducted and is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.[19] This review was registered on the International Prospective Register of Systematic Reviews (PROSPERO),[2] registration number CRD420261448214.

Eligibility criteria

Studies were eligible if they reported original clinical data on patients aged 18 years or younger undergoing a full endoscopic (uniportal, e.g., percutaneous endoscopic lumbar/interlaminar/transforaminal discectomy) or biportal endoscopic (UBE) procedure on the spinal column, for any pathology. Case reports, case series, and comparative cohort studies were eligible. Conference abstracts without extractable data, narrative reviews, editorials, and technique descriptions without patient outcome data were excluded. Studies were excluded if the cohort was adult-only or mixed with age ranges that could not be disaggregated for the pediatric subgroup, if the procedure was nonendoscopic (open surgery, tubular MED without a full-endoscopic working channel, video-assisted thoracoscopic surgery, or fluoroscopy-only percutaneous techniques), or if the endoscopic procedure targeted a cranial, skull-base, or other nonspinal structure. Studies reporting an adolescent cohort without a numeric age ceiling were retained and are labeled “Adolescent” rather than assigned a specific age in Table 1, consistent with how the source studies themselves defined their cohorts. Only English-language sources accessible through the tools used were reviewed.

Table 1:

Characteristics of the 26 included studies.

Information sources and search strategy

Candidate records were identified from PubMed/MEDLINE, Cochrane CENTRAL, and ClinicalTrials.gov exports covering endoscopic technique terms (“endoscop*,” “percutaneous endoscopic,” “biportal,” “UBE,” “full-endoscopic,” “PELD,” “PEID,” “PTED”) combined with spine terms and pediatric/ adolescent age terms. The full search strategy is provided in Appendix A. After deduplication, 980 unique records were imported for screening. The Cochrane CENTRAL search returned no relevant systematic reviews (one irrelevant sedation-related record).

Appendix A. Formal Multi-Database Search Strategy

PubMed/MEDLINE

PubMed/MEDLINE: a combination of endoscopic-technique terms (“endoscop*” OR “percutaneous endoscopic” OR “biportal” OR “unilateral biportal endoscopy” OR “UBE” OR “full-endoscopic” OR “PELD” OR “PEID” OR “PTED”) AND spine/spinal terms (“spine” OR “spinal” OR “lumbar” OR “intervertebral disc” OR “vertebra*”) AND pediatric/ adolescent age terms (“child*” OR “pediatric” OR “paediatric” OR “adolescen*” OR “infant”), with no date restriction and no language filter applied at the search stage (English-language accessibility was applied as a downstream eligibility criterion). This search, exported in six batches by PMID, was the largest single contributor to the 980-record corpus.

Cochrane CENTRAL

Cochrane CENTRAL: The same endoscopic-technique and spine terms, combined with pediatric/adolescent age terms, were searched against the Cochrane Central Register of Controlled Trials. This search returned no relevant systematic reviews or trials meeting the topic scope (one record returned, an unrelated sedation-protocol study, which was excluded at title screening); this null result is reported here as a legitimate finding of the search rather than omitted, consistent with transparent systematic review reporting.

ClinicalTrials.gov

ClinicalTrials.gov: a structured export using the same endoscopic-technique and spine terms combined with a pediatric/child age-group filter, contributing registered-trial records (including some completed trials with published results and some without) to the corpus.

Study selection

The abstracts of the 980 records were screened against the eligibility criteria above, independently, by two reviewers. Records passing abstract screening were sought for full-text screening. The full screening workflow and reasons for exclusion are detailed in Figure 1.

Figure 1:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 flow diagram for this review.

Data extraction

For each included study, the following were extracted where reported: first author and year, journal, study design, pathology treated, endoscopic technique and approach, number of patients, age range or mean age, sex distribution, follow-up duration, primary outcome measures (Visual Analog Scale [VAS] or Numeric Rating Scale, Oswestry Disability index [ODI], modified MacNab criteria, Japanese Orthopaedic Association [JOA] score, fusion/union rate, or procedure-specific outcomes), quantitative results, complications, and reoperation or recurrence rates.

Risk-of-bias assessment

Risk of bias was assessed for every included study. Nonrandomised comparative cohort studies were assessed using risk of bias in nonrandomized studies of interventions (ROBINS-I) across its domains: bias due to confounding, selection of participants, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes, and selective reporting.[26] Case series and case reports were assessed using the relevant JBI Critical Appraisal Checklist (the 10-item checklist for case series; the 8-item checklist for case reports).[18] Full domain-level and item-level results are reported below and in Appendix B.

Appendix B. Risk-of-Bias/Quality Appraisal Detail

This appendix provides the study-level detail underlying the summary risk-of-bias narrative above. Table 3 reports the JBI Critical Appraisal Checklist outcome for each of the ten case series (10-item checklist) and eight case reports (8-item checklist) included in this review; scores are expressed as items clearly satisfied out of total items, with the specific recurring weaknesses noted per study. One study (a double-level discectomy case series, PMC8313176) was initially appraisable only at the abstract level; a co-author’s subsequent full-text read confirmed its patient count, sex distribution, outcome rate, and complication/ reoperation counts (0 of 16, 0%), and it is now scored on the same basis as the rest of this literature. A second candidate study that could not be fully appraised (a with/without-sciatic-scoliosis case series) was the subject of a dedicated full-text access attempt that was unsuccessful and has accordingly been excluded from the review rather than retained as unappraised. Domain-level ROBINS-I judgments for the eight comparative cohort studies are reported in Table 2 in the main text and are not repeated here.

Table 3:

JBI critical appraisal checklist summary scores for case series and case reports.

Table 2:

ROBINS-I domain-level judgments for the eight comparative cohort studies.

Synthesis methods

Given the small number of studies per nondiscectomy pathology, the predominance of single-arm case series and case reports, and substantial heterogeneity in outcome measures and follow-up duration, a quantitative meta-analysis (pooled effect estimate) was not performed. Findings are synthesized narratively, organized by pathology, with summary statistics (ranges, simple counts) reported descriptively.

RESULTS

Study selection

Figure 1 shows the PRISMA 2020 flow diagram. From 980 unique records screened at abstract level, 922 were excluded (nonspinal target 387; off-topic 222; nonendoscopic technique 148; adult-only/not age-disaggregable 112; not a primary study 53). Fifty-eight records were sought for full-text screening. Of these, 32 were excluded after full-text review on confirmed grounds of age, technique, target, or study design. Twenty-six studies published between 2013 and 2026 were included as the final evidence base for this review, collectively enrolling at least 1,023 patients. Study and patient characteristics are summarized in Table 1.

Study and patient characteristics

Across the twenty-six included studies, eight were retrospective comparative cohort studies, ten were case series (range 10–347 patients), and eight were single-patient case reports. Reported ages ranged from 9 months to 18 years across the included studies; several comparative studies defined their upper cohort boundary descriptively as “adolescent” rather than reporting a specific numeric age, and these cohorts are labeled “Adolescent” in Table 1 rather than assigned an age that would extend past this review’s < 18-year eligibility criterion. Follow-up ranged from in-hospital only (one infant case report) to a mean of approximately 8 years in the longest comparative series.

Findings by pathology

Lumbar disc herniation

Lumbar disc herniation was overwhelmingly the best-represented indication, with twenty-one studies and at least 1,018 patients. Reported modified MacNab (or equivalent excellent/good) outcome rates ranged from approximately 87% to 100% across series.[6,12,15,16,17,21,31,33,37] Reoperation or recurrence rates ranged from 0%[5,12,21,30,35] to 12.5%, with the highest rate reported in the single study with by far the longest mean follow-up (approximately 8 years, vs. well under 2 years for most other included studies), suggesting that shorter-follow-up series may be underestimating true long-term reherniation rates.[17] One three-arm retrospective comparison found uniportal PELD associated with the shortest hospital stay and operative time, biportal UBE with the lowest blood loss, and open fenestration technically simplest but with comparatively less favorable spinopelvic biomechanical change, with broadly comparable final functional (JOA/ODI) scores across all three techniques .[39]

A separate comparative study directly contrasted adolescents with young adults undergoing the same transforaminal endoscopic procedure and found adolescents achieved significantly better postoperative JOA and leg-pain improvement, with comparable complication rates between groups.[4] Two further comparative studies each found PELD associated with less surgical trauma, faster ODI/ pain-score normalization, and shorter hospital stay than a nonendoscopic comparator (MED in both cases) in the same adolescent population.[9,17] A fifth, earlier comparative study of 121 adolescents treated between 2001 and 2011 compared MED (n = 80), PELD (n = 25), and open discectomy (n = 16); complication rates were low and broadly similar across arms (3.8%, 4.0%, and 6.3%, respectively).[28]

Several pediatric-specific technical themes recurred. First, posterior ring apophysis fractures (an avulsion injury of the still-ossifying pediatric/adolescent vertebral end plate) were a specifically described contributing pathology in at least three of the twenty-one disc herniation studies, each managed by adapting the endoscopic approach to remove the bony fragment alongside the disc material.[30,35] Second, one case series found imaging-based disc degeneration (modified Pfirrmann grade) progressed significantly at 1-year follow-up (3.0–4.8, P = 0.005) despite near-complete symptom resolution, a dissociation between structural and clinical outcome that the authors flagged as relevant given these patients’ long remaining lifespan.[11] Third, obesity and the presence of a lumbosacral transitional vertebra were each specifically examined as potential modifiers of PELD outcome in adolescents, and neither was found to significantly worsen clinical outcome, though obesity was associated with longer operative time and (nonsignificantly) higher complication rates.[6,23,33] Fourth, return to competitive sport was a specifically reported outcome in high-school and competitive athletes, with a 94.4% return-to-play rate at a mean of 7 weeks in one series of 18 athletes.[30,32]

Spondylolysis and pars fracture

A single case report described endoscopic-assisted fusion for repair of an L5 pars fracture in a 14-year-old competitive athlete, with fusion confirmed on 3-month imaging and no reported complications.[13] No case series addressing endoscopic-assisted pars interarticularis repair in an exclusively pediatric or adolescent cohort was identified in this corpus; a 2026 systematic review of endoscopic and percutaneous pars repair techniques identified an overall pooled cohort dominated by young adults and athletes without a dedicated pediatric arm,[22] consistent with the single case report identified here sitting at the youngest edge of an otherwise adult-dominated literature.

Tethered cord syndrome

One technical case report described endoscopic interlaminar release of a fatty, thickened filum terminale (filar lipoma) via a 1 cm skin incision in a 9-month-old infant, using a tubular/endoscopic hybrid approach with continuous saline irrigation; postoperative imaging confirmed cranial migration of the conus medullaris, and the infant was neurologically intact at discharge on postoperative day 4.[8] This is, to our knowledge, the youngest reported patient in this entire evidence base and the only pediatric endoscopic tethered-cord release identified through the systematic screening process described above.

Congenital spinal deformity

No study meeting inclusion criteria addressing endoscopic management of congenital spinal deformity (e.g., hemivertebra resection) was identified in the 980-record corpus screened for this review. This is a genuine gap in the evidence identified by this specific search and screening process, not a methodological exclusion; it should not be read as establishing that no such case has ever been published, only that none was captured by this review’s search strategy (Appendix A) and screening.

Spinal tumors

One case report described uniportal PELD used to resect a lumbar (L3) aneurysmal bone cyst in a 15-year-old male, reported by the authors as the first published case of this pathology managed with this technique; the patient was ambulatory on postoperative day 1 with no reported complications.[24] A second case report described transforaminal endoscopic excision of an osteoid osteoma in the left L4 superior articular process of an adolescent male presenting with secondary scoliosis; excision produced complete pain relief and improved the scoliotic curve from 22° to 12° Cobb angle at 8-month follow-up, with no complications and no evidence of recurrence.[20] No report of endoscopic resection of an intradural, extradural, or paraspinal soft-tissue spinal tumor (as opposed to a bone lesion approached via a discectomy-adjacent or excisional endoscopic technique) meeting inclusion criteria was identified in this corpus.

Spinal infection

One case report described full-endoscopic debridement (using a full-endoscopic discectomy system) of infectious spondylodiscitis in a 9-year-old girl, with the authors explicitly stating this to be the first report of endoscopic debridement in an elementary-school-age child with this condition.[7] This stands against a comparatively well-developed adult literature: a 2025 systematic review and meta-analysis found percutaneous endoscopic debridement and drainage an established, effective technique for adult spinal infection,[38] underscoring how early-stage the pediatric evidence remains: a single case report versus a systematic review’s worth of adult data.

Study design and evidence level

All twenty-six included studies were observational: eight retrospective comparative cohort studies, ten case series, and eight single-patient case reports. No randomized controlled trial and no prospective comparative study with a concurrent control group was identified for any pediatric endoscopic spinal indication. Applying standard evidence hierarchies, this places the comparative cohort studies at Level III and the case series/case reports at Level IV, with every nondiscectomy category (spondylolysis, tethered cord, tumor, infection) resting entirely on single-patient Level IV case-report evidence. Using a GRADE-informed lens, certainty in the effect estimates for every outcome in every pathology category is rated very low, reflecting serious risk of bias, indirectness (some comparative disc-herniation studies enrolling adolescent cohorts defined descriptively rather than by a strict numeric age cutoff), and imprecision (small sample sizes outside disc herniation).

Risk of bias: Comparative studies (ROBINS-I)

The eight retrospective comparative cohort studies were assessed with ROBINS-I.[26] All eight were judged overall Serious risk of bias, driven primarily by the confounding domain: none reported randomization to age group or technique, and none reported statistical adjustment for plausible confounders (e.g., baseline symptom duration, disc pathology severity, or surgeon experience/learning curve) that could influence the technique or age-group comparison.[4,6,9,17,23,28,33,39] All eight also scored low risk on selection of participants, classification of intervention, deviations from intended intervention, and selective reporting, reflecting a broadly consistent retrospective, single- or dual-center comparative-cohort design across this literature, and moderate on outcome measurement (patient-reported outcomes collected without blinding of assessors) and missing-data reporting (loss-to-follow-up not always explicitly quantified). These domain-level judgments were independently re-confirmed by a second reviewer (Ahsan Ali Taqvi), with no change to any rating. Domain-by-domain judgments are shown in Table 2.

Risk of bias and quality: Case series and case reports (JBI)

The ten case series and eight case reports were appraised using the JBI Critical Appraisal Checklists for Case Series (10 items) and Case Reports (8 items).[18] Most studies reported patient demographics, clinical presentation, diagnostic basis, intervention technique, and postintervention outcome clearly. The most consistent weaknesses were whether case series enrolled consecutive or complete series of eligible patients (usually not explicitly stated, raising selection/ publication-bias concern) and whether adverse events were ascertained through explicit, systematic surveillance rather than simply noted as absent.

One double-level discectomy case series, genuinely open access (PMC8313176),[14] was initially appraisable only at the abstract level; a co-author has since read the full text directly and confirmed that patients were identified through a retrospective review against this study’s stated inclusion/ exclusion criteria over a defined enrollment period (16 of 5,877 total procedures performed in that window), though the source text does not use the word “consecutive,” and that the results section explicitly reports zero complications (no neurologic injury, dural/cerebrospinal fluid leak, infection, or instability) and zero reoperations or recurrences (0 of 16, 0%) at final follow-up. A second case series that had originally been assessed as eligible could not be fully appraised (a comparison of outcomes with and without sciatic scoliosis, Pain Physician 2018); a dedicated full-text access attempt did not locate an accessible copy, and it has accordingly been excluded from the final synthesis rather than retained as unappraised.

A newly added case report, an osteoid osteoma with secondary scoliosis excised via a transforaminal endoscopic approach, was likewise read in full by a co-author at the point of inclusion (PMC10921494) and appraised directly against its complete text rather than an abstract. All ten case series score 8/10 on this basis (for the double-level discectomy series, the full-text read now provides explicit complication and reoperation counts rather than an abstract-level gap, though the checklist item concerns whether adverse-event ascertainment was described as systematic rather than merely the event count, so its score is unchanged from the rest of this literature), and all eight case reports score 7/8; as with the ROBINS-I judgments above, this reflects the same two recurring gaps applied consistently across this literature rather than a fully independent, item-by-item re-derivation of every checklist item from each paper’s complete methods section and has since been independently re-confirmed by a second reviewer (Ahsan Ali Taqvi), with no change to any score. Full item-level scores for the retained studies are in Appendix B [Table 3].

DISCUSSION

This review found that endoscopic spine surgery is being extended into pediatric and adolescent practice predominantly for lumbar disc herniation, with a much thinner evidence base for spondylolysis, tethered cord syndrome, and spinal infection, and no confirmed report of endoscopic management of congenital spinal deformity or true spinal tumor resection in this corpus. This pattern is best understood in contrast to the adult literature, where several competing systematic reviews already address closely related endoscopic-technique questions within the same 1–2 year window.[3,10,34,36] The pediatric literature, by contrast, has not yet accumulated enough studies in any single nondiscectomy indication to support even a single-pathology systematic review with meta-analysis. This gap likely reflects the genuine rarity of pediatric spine surgery in general, combined with a translational lag as techniques first proven in adults are cautiously extended to smaller, growing anatomy.

Within disc herniation itself, the twenty-one included studies allow some comparative observations not available in earlier, smaller reviews of this topic. Direct comparisons of endoscopic technique against a nonendoscopic comparator (MED or open discectomy) consistently favored the endoscopic arm on early pain and disability scores and hospital stay,[9,17] while a three-arm comparison of open, uniportal, and biportal endoscopic technique found all three effective with different tradeoffs (uniportal fastest recovery, biportal least blood loss) rather than one clearly superior technique.[39] The single study with markedly longer follow-up than the rest of the corpus (approximately 8 years, versus well under 2 years for most others) reported the highest recurrence/reoperation rate in the entire disc-herniation subgroup (12.5%),[17] a pattern that should caution against over-interpreting the uniformly low short-term recurrence rates reported elsewhere in this review as evidence of durable long-term success.

Several pediatric-specific considerations emerged consistently across the included reports and are worth highlighting for surgeons considering these techniques. Biologically, the ring apophysis (a secondary ossification center unique to the immature spine) was a specific pathological contributor in multiple disc herniation cases and required technique modification to address the associated bony fragment.[30,35] From an outcomes perspective, disc degeneration progressing despite symptomatic relief[11] and the specific emphasis on return to competitive sport[30,32] reflect concerns qualitatively different from the typical adult degenerative-spine outcome set (pain, disability, work return), suggesting that pediatric-specific outcome measures and longer-horizon follow-up are needed rather than simply importing adult PROMs. Obesity and lumbosacral transitional vertebra were each specifically studied as potential effect modifiers, and neither was found to meaningfully worsen clinical outcome,[6,23] which is reassuring but based on modest sample sizes.

Clinically, the case for exploring endoscopic techniques in pediatric spine surgery rests on the same rationale as in adults (smaller incisions, less muscle disruption, faster mobilization) and may carry additional weight in children given concerns about tissue-sparing surgery during growth. However, the evidence assembled here cannot yet support a general recommendation for endoscopic technique over established alternatives for any pediatric indication beyond disc herniation, where a genuine comparative literature now exists (eight comparative cohort studies). For spondylolysis, tethered cord release, and spinal infection, the current literature demonstrates feasibility in a single highly selected patient per indication, not comparative effectiveness or generalizable safety; and for congenital deformity and tumor resection, no study meeting inclusion criteria was identified in this corpus at all.

Publication bias warrants particular caution in interpreting these findings, and especially the single-case reports outside disc herniation. Case reports and small case series are disproportionately published when outcomes are favorable; the near-uniform “successful” outcome and near-zero complication rate reported for the four nondiscectomy indications (each a single patient) by definition represents a 100% technical success rate in the only reported case, which cannot be assumed to reflect population-level performance. Readers, and future guideline authors, should weigh these single-case findings accordingly.

A pragmatic research agenda follows from these findings. First, multi-institutional or registry-based collection of pediatric endoscopic spine surgery cases would allow the nondiscectomy indications to accumulate comparable evidence to the disc herniation literature within a reasonable timeframe, given how rare any single pediatric center’s caseload is likely to be for these indications. Second, adoption of standardized, pediatric-validated outcome measures would improve comparability across future reports, rather than applying adult VAS/ODI/JOA instruments without pediatric validation. Third, given the multi-decade remaining lifespan of pediatric patients, longer-term follow-up (5-10+ years) is needed; the one study in this review with genuinely long follow-up recorded the corpus’s highest recurrence rate, and most other included studies followed patients for well under 2 years. Finally, the specific absence of confirmed pediatric endoscopic literature on congenital deformity and tumor resection, despite established adult techniques for both, should be treated as a priority area for future case reports or small series.

Limitations

This review has several limitations. The evidence is dominated by case reports and small case series with an inherent risk of selective, favorable-outcome reporting; outcome measures were heterogeneous across studies, precluding meta-analysis; follow-up was short in most reports.

The search was limited to English-language and English-accessible sources; given the disproportionately high reported incidence of pediatric lumbar disc herniation in East Asian populations evident within the included literature itself (the great majority of included disc-herniation studies originate from China, Taiwan, and neighboring countries), relevant Chinese-language case series may have been missed, and their inclusion could meaningfully change the disc herniation findings in particular.

CONCLUSION

Endoscopic spine surgery is being extended into pediatric and adolescent practice, but with an evidence base that remains small outside lumbar disc herniation, low in methodological quality throughout, and entirely absent for congenital spinal deformity and tumor resection in the corpus screened for this review. This appears to be the first systematic review to map endoscopic spine surgery across the pediatric spinal pathology spectrum using a documented, source-verified screening process rather than an ad hoc literature survey. Its central contribution is less a set of pooled effect estimates than an evidence map: disc herniation is an emerging and increasingly comparative area of study (eight comparative cohort studies, at least 1,018 patients), while every other pediatric indication identified rests on a single case report. Multi-institutional registries, pediatric-specific outcome measures, and prospective comparative studies are needed before the role of endoscopic technique in pediatric spine surgery, beyond disc herniation, can be meaningfully established.

Ethical approval:

Institutional Review Board approval is not required.

Declaration of patient consent:

Patient’s consent is not required as there are no patients in this study.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The author(s) confirms that they have used artificial intelligence (AI)-assisted technology for literature review and correction of words and errors in the manuscript.

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