Endoscopic Diskectomy in Athletes: A Systematic Review and Meta-analysis

Abstract

Athletes are at increased risk of lumbar disk herniation due to degenerative and traumatic factors. Prior studies have evaluated the efficacy of traditional open diskectomy in athletes; however, there is limited evidence regarding the utility of endoscopic diskectomy for athletes recovering from lumbar disk herniations. Our objective is to evaluate the efficacy of endoscopic diskectomy in athletes with lumbar disk herniation, focusing on return to play and pain outcomes. Studies on athletes with lumbar disk herniation who underwent endoscopic diskectomy were included. Case reports and case series with fewer than 10 patients were excluded. PubMed-Medline and Ovid-Medline databases were searched, with the last search conducted in May 2024. Quality assessment/risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS) tool for non-comparative studies. Data were synthesized using a random effects model. Meta-analyses were conducted using R software (R Core Team, 2024). Four studies with a total of 119 athletes were included. The combined return to play rate was 96% (95% CI: 90–100%), with a mean return to play time of 8.25 weeks (95% CI: 6.51–10.46 weeks). The mean differences in leg and back VAS were −68.83 (95% CI: −102.05 to −35.61) and −68.42 (95% CI: −101.45 to −35.40), respectively. Endoscopic diskectomy in athletes is associated with high return to play rates and significant pain reduction. Future studies that stratify outcomes based on the level of competition and specific endoscopic diskectomy technique are needed to fully assess the utility of endoscopic diskectomy in athletes.

 

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Keywords

endoscopic diskectomy - percutaneous endoscopic lumbar diskectomy - microendoscopic diskectomy - athletes - return to play

Introduction

Athletes present unique injury risk factors and care considerations for spinal disorders. Among elite athletes, low back pain has a considerable impact on playing time.[1] Furthermore, participation in competitive athletics may be associated with increased risk of degenerative disk disease and lumbar disk herniation caused by microtrauma and chronic pressure on the spine without adequate time to heal.[2] [3] Management of symptomatic disk herniation in athletes involves return to play evaluations on an individual basis with consideration of the patient's type of sport and position.[4] In a systematic review of elite athletes with lumbar disk herniation, return to play rates varied and depended on the type of sport played. Major League Baseball (MLB) players had the greatest return to play rate, while National Football League (NFL) players had the lowest return to play rate.[5] Interestingly, there was no significant difference in return to play outcomes in patients who were treated conservatively and patients who underwent diskectomy; however, patients in the NFL who underwent diskectomy had a longer postoperative career length compared to patients who received conservative treatment. The opposite was true for patients in the MLB.[5]

A systematic review regarding return to play rate in athletes following traditional lumbar diskectomy reported return to play rates ranging from 75 to 100%.[6] Average time to return to play ranged from 2.8 to 8.7 months.[6] Postoperative performance depended on the athlete's chosen sport, with hockey players experiencing the greatest decline in performance, while football players experienced a slight performance improvement.[6] Regardless, there is a place for lumbar diskectomy in the management of lumbar disk herniation in elite athletes.

Although studies have been performed regarding traditional diskectomy in athletes, there is little evidence regarding endoscopic approaches in athletes. Percutaneous endoscopic lumbar diskectomy (PELD) and microendoscopic diskectomy (MED) have been shown to have no difference in postoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) scores with decreased postoperative length of stay and return to work time compared to traditional open diskectomy in the general population.[7] [8] [9] [10] [11] PELD refers to a 6- to 7-mm diameter cannula, inserted percutaneously under fluoroscopic guidance through either the transforaminal or interlaminar space to access the disk herniation.[12] MED refers to procedures that employ serial dilations and a wider tubular retractor system into which a rigid functional endoscope is inserted.[12] In this systematic review and meta-analysis, we define return to play rate and return to play time in athletes undergoing endoscopic diskectomy with either method for lumbar disk herniations. Further, we assess the difference in preoperative and postoperative VAS scores.

 

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Materials and Methods

Search Strategy

A systematic literature review regarding endoscopic diskectomy in athletes was performed using Pubmed-Medline and Ovid-Medline, with the last search in May of 2024. Keywords searched included athletes, endoscopic surgery, and spine. Due to the exploratory nature of this study, PROSPERO registration was not performed. A total of 254 papers were identified on the initial search. For further review 12 papers were selected by title. Four papers were included in the study after complete analysis of the paper.

 

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Inclusion Criteria

Inclusion criteria were defined using the PICOS format. Population: Athletes with lumbar disk herniation at all levels of competition. Intervention: Percutaneous or microendoscopic diskectomy. Comparison group was not necessary for this study. Outcomes: Proportion of patients returning to play and the number of weeks from the date of surgery to the return to play date. Postoperative VAS was not a requirement for inclusion but was extracted when present. Study design: Retrospective review or prospective cohort studies were eligible for inclusion.

 

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Exclusion Criteria

Case reports and case series with fewer than 10 patients were excluded. Studies were excluded if they did not report the return to play time or proportion of athletes who returned to play.

 

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Data Collection

The return to play time and the proportion of athletes who returned to play were extracted. Herein, return to play denotes the return to full participation at an equal or greater level compared to before the disk herniation. Patients who returned to play at a lower level, or did not return to play at all, were not included in the “return to play” group. Preoperative/postoperative VAS were extracted when present. One reviewer extracted the data from each study.

 

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Quality/Risk of Bias Assessment

Quality and risk of bias were evaluated across several domains using the Methodological Index for Non-Randomized Studies (MINORS) tool. Studies were scored 0 (not reported), 1 (inadequately reported), and 2 (adequately reported) regarding a number of domains measuring methodological quality and potential bias. Two reviewers selected the studies for inclusion and performed the quality/risk of bias assessment. The PRISMA 2020 guidelines for reporting systematic reviews were utilized for this study.[13]

 

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Statistical Analysis

All statistical analyses were performed using R software, version 4.3.0 (R Core Team, 2024). Meta-analyses were conducted using the “meta” package (Schwarzer, 2007). A random effects model was employed to account for variability among studies, with between-study variance (τ²) estimated using the restricted maximum likelihood (REML) method. Studies were weighted based on number of participants and precision of collected data. Studies including outcome measures of interest were included in meta-analysis. Forest plots were generated to visualize the effect sizes, and heterogeneity was assessed using the I ² statistic. Where standard deviations (SD) were not reported, they were estimated by dividing the range by 4.

 

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Results

Study Characteristics

Four studies, involving 119 total patients, were included. Of these studies, one included high school athletes,[14] one included elite competitive athletes,[15] and two included a combination of both amateur and professional athletes (high school, collegiate, semi-professional, and professional) ([Table 1]).[16] [17] All studies included athletes presenting with symptomatic lumbar disk herniation. All studies included single-level endoscopic diskectomy. Mean follow-up time was greater than 2 years in all studies. Additional demographic information, including represented sports, is presented in [Table 1]. PRISMA flow diagram outlining the literature search and study inclusion processes is presented in [Fig. 1].[13]

Fig. 1 Flow diagram of literature search and study inclusion process.

Table 1 Characteristics of included studies

Author	Study design	n	Mean age	Preoperative diagnosis	Surgery type	Number of levels	Competition level	Sport	Study location	Mean return to play time (weeks)	Return to play rate	Mean follow-up period (months)
Yamaya et al,[14] 2020	Case series	18	17	Lumbar disk herniation	PELD	Single level	High school	Track and field, wrestling, American football, table tennis, basketball, rugby, softball, baseball, dance	Japan	7.0 ± 3.5	0.944	27
Yoshimoto et al,[16] 2013	Case series	25	19.4	Lumbar disk herniation	MED	Single level	High school	Baseball, basketball, badminton, soccer, volleyball, rugby, other	Japan	10.8 ± 3.8	0.826	22.8
Nakamae et al,[17] 2019	Case series	21	22.9	Lumbar disk herniation	PELD	Single level	Pro, semi-pro, club, high school, collegiate	Football, baseball, volleyball, tennis, track and field, basketball, cycling, boxing, ping pong	Japan	9.2 ± 5.5	0.950	28.1
Kapetanakis et al,[15] 2021	Case series	55	24.4	Lumbar disk herniation	PELD	Single level	Professional athletes	Basketball, volleyball, weightlifting, wrestling	Greece	6.7 ± 0.3	1.000	24

Abbreviations: MED, microendoscopic diskectomy; PELD, percutaneous endoscopic lumbar diskectomy.

 

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Quality/Risk of Bias Assessment

The MINORS tool was used to assess the quality and risk of bias in the included studies. All of the included studies adequately reported the aim of the study, the endpoints assessed, and the follow-up period. Therefore, each study was given a score of “2” in each of these domains ([Table 2]). None of the included studies mentioned the prospective calculation of the study size necessary to achieve adequate statistical power, and all studies received a score of “0” in this domain. Yoshimoto et al somewhat adequately mentioned that three patients were not included in their return to play analysis because they did not return to athletics for reasons other than their back or leg pain.[16] Therefore, they received a score of “1” in the loss to follow-up category. All other studies included all patients in their final analysis, and received scores of “2.” All studies except for Yamaya et al mentioned the inclusion of consecutive patients.[14] Only Kapetanakis et al conducted a prospective study.[15] Regarding unbiased outcome measures, only Nakamae et al used independent evaluators while collecting postoperative outcomes data.[17] Therefore, they received a score of “2” for the unbiased endpoint category. All the other studies discussed their outcome assessment process but did not mention using independent evaluators, and where therefore given a score of “1.” Overall, all of the included studies scored in the moderate (9–12) to high (13–16) quality range, indicating low to moderate risk of bias ([Table 2]). A summary of the risk of bias assessment is provided in [Table 2].

Table 2 Quality/risk of bias assessment for included studies

Study	Aim	Consecutive patients	Prospective data	Endpoints	Unbiased endpoint	Follow-up period	Loss to follow-up	Study size calculation	Total (out of 16)
Yamaya et al,[14] 2020	2	0	0	2	1	2	2	0	10
Yoshimoto et al,[16] 2013	2	2	0	2	1	2	1	0	10
Nakamae et al,[17] 2019	2	2	0	2	2	2	2	0	12
Kapetanakis et al,[15] 2021	2	2	2	2	1	2	2	0	13

 

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Return to Play Rate

All four studies reported the mean return to play percentage in athletes following endoscopic diskectomy.[14] [15] [16] [17] The combined percentage of athletes returning to full participation was 96% (95% CI: 90%; 100%, I ² = 49%, t² = 0.0017, p = 0.12) with a range of 83 to 100%. Aggregated return to play rate is summarized in [Fig. 2].

Fig. 2 Aggregated return to play rate in athletes following endoscopic diskectomy.

 

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Return to Play Time

All four studies reported the mean return to play time in weeks following endoscopic diskectomy.[14] [15] [16] [17] The combined mean return to play time was 8.25 weeks (95% CI: 6.51; 10.46, I ² = 97%, t² = 0.0508, p < 0.01) with a range of 6.7 to 10.8 weeks.[14] [15] [16] [17] Aggregated return to play time is summarized in [Fig. 3].

Fig. 3 Aggregated return to play time (weeks) in athletes following endoscopic diskectomy.

 

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VAS Outcomes

Two out of the four studies reported mean preoperative and postoperative VAS outcomes with standard deviations.[15] [17] The combined mean difference in preoperative and postoperative leg VAS showed a 68.83-point decrease in pain scores following surgery (95% CI: −102.05; 35.61, I ² = 100%, t² = 573.493, p < 0.01). The combined mean difference in preoperative and postoperative back VAS showed a 68.42-point decrease in pain scores following surgery (95% CI: 101.45; 35.40, I ² = 100%, t² = 566.69, p < 0.01). There was very high heterogeneity between studies in preoperative VAS scores. Aggregated mean differences in VAS back and leg scores are summarized in [Figs. 4] and [5].

Fig. 4 Aggregated mean difference in low back VAS in athletes following endoscopic diskectomy.

Fig. 5 Aggregated mean difference in leg VAS in athletes following endoscopic diskectomy.

 

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Discussion

Endoscopic diskectomy has emerged as a minimally invasive alternative to open diskectomy for lumbar disk herniation. Prior studies have shown no difference in postoperative VAS or ODI scores, a decreased length of hospital stay, and reduced return to work time when compared with open diskectomy in the general population.[7] [8] [9] [10] [11] These findings are likely the result of reduced soft tissue and paraspinal muscular damage associated with the minimally invasive approach.[18] [19] This makes endoscopic diskectomy a potentially attractive alternative to open diskectomy in athletes who hope to expedite recovery and return to play.

In this meta-analysis, four studies with 119 patients who underwent endoscopic diskectomy for lumbar disk herniation were analyzed. The combined return to play rate was 96% by random effects modeling. Kapetanakis et al studied 55 competitive elite athletes and found the return to play percentage was 100%.[15] Yamaya et al studied only high school athletes and found the return to play rate was 94%.[14] Yoshimoto et al studied class 3 (high recreational and high school athletes) and class 4 (college and professional athletes) and found the return to play rate was 83%.[16] Nakamae et al studied both amateur and professional athletes and found the return to play rate was 95%.[17] There was some heterogeneity between studies regarding return to play rate, likely due to the inclusion of athletes from different levels of competition. Regardless, the combined return to play rate in athletes following endoscopic diskectomy is in the higher end of the 75 to 100% range, reported by a prior systematic review on traditional open diskectomy in athletes.[6] Based on this data, there is evidence that athletes undergoing endoscopic diskectomy have a high likelihood of returning to play following surgery.

The combined average return to play time in this study was 8.25 weeks.[14] [15] [16] [17] A prior systematic review on traditional diskectomy in elite athletes found that the range of return to play time was 2.8 to 8.7 months (11.2–34.8 weeks).[6] By comparison, the combined return to play time is shorter in athletes who underwent endoscopic diskectomy. These data, when combined with prior studies showing that PELD decreased length of hospital stay and return to work time compared to traditional diskectomy in the general population, suggest that there may be a utility for endoscopic diskectomy in athletes.[7] [8] [9] [10] [11] With decreased length of hospital stay and postoperative recovery time (as evidenced by decreased return to work time in the general population and a relatively short return to play time), athletes may be able to begin rehabilitation earlier, which could improve return to play time.

There was a high degree of heterogeneity regarding return to play time between the included studies. Kapetanakis et al found that the return to play time for elite athletes was 6.7 weeks, which is shorter than the combined return to play time;¹⁵ however, Yoshimoto et al found that the return to play time for class 4 athletes (collegiate and professional) was 11 weeks, which is longer than the combined return to play time.[16] Likewise, Yamaya et al found the return to play time was 7 weeks for high school athletes, while Yoshimoto et al found that return to play time was 10.8 weeks in high school and high recreational athletes.[14] [16] Even within a level of competition, there is still significant differences in return to play time. This indicates that the return to play process has more to do with the specific needs of individual athletes than with the competition level.

Additionally, although all included studies assessed endoscopic diskectomy, the differences in technique between MED and PELD may account for some of the heterogeneity in return to play time. Yoshimoto et al were the only investigators who reported outcomes following MED, and the return to play rate and return to play time were 10.8 weeks and 83% respectively,[16] compared to studies examining PELD, which had return to play time and proportion ranging from 6.7 to 9.2 weeks and 94 to 100%, respectively.[14] [15] [17] Given these results, it appears PELD may be the better surgical approach in athletes with disk herniations. However, given that only one MED study was included, any assumptions about the superiority of PELD should be made with caution. Further studies comparing return to play time in elite and amateur athletes and comparing patients who underwent MED and PELD would help evaluate the utility of endoscopic diskectomy in athletes based on level of competition and surgical approach.

Two studies reported postoperative VAS outcomes with standard deviations. Both studies included athletes who underwent PELD, and the combined mean difference in preoperative and postoperative VAS was 68.83 for leg pain and 68.42 for back pain; however, there was significant heterogeneity between the two studies. Nakamae et al studied a combination of amateur and professional athletes and reported a preoperative leg VAS of 64.3 ± 2.7 and a postoperative leg VAS of 12.4 ± 1.4. They reported a preoperative mean low back VAS of 62.1 ± 2.2 and a postoperative back VAS of 10.5 ± 1.1.[17] Kapetanakis et al studied elite athletes and reported a preoperative mean leg VAS of 90.7 ± 8.1 and a postoperative mean leg VAS of 4.9 ± 5.7. They reported a preoperative mean back VAS of 90.4 ± 8.6 and a mean postoperative back VAS of 5.1 ± 6.1.[15] Though both studies had similar mean postoperative VAS scores, Kapetanakis et al showed higher preoperative leg and back VAS scores.[15] [17] It is possible that elite athletes had more severe injuries compared to amateur athletes due to higher levels of stress on their bodies. Further research is needed to clarify the effect of endoscopic diskectomy on postoperative VAS in elite and amateur athletes stratified by level of competition.

 

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Limitations

Potential limitations of this meta-analysis include the small number of included studies, although this highlights the relative recency and paucity of data regarding endoscopic diskectomy in athletes. Given the small number of included studies, it was not possible to examine the literature for publication bias, which limits the conclusions that can be made from this meta-analysis. Additionally, inconsistent reporting of standard deviations in the included studies and estimation of these values is a limitation of our statistical analysis regarding return to play time. Finally, the lack of postoperative functional metrics, including whether athletes achieved the same level of success following return to play, limits the clarity regarding whether endoscopic diskectomy was truly successful in athletes.

 

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Conclusion

Athletes who underwent endoscopic diskectomy for single-level lumbar disk herniation had a high rate of return to play with a short return to play time when compared to existing data on traditional open diskectomy. There was a large reduction in VAS postoperatively, indicating endoscopic diskectomy improves pain in athletes with lumbar disk herniation. Additional investigation with stratification based on level of athletic competition, more granular data on sport and position played, and specific endoscopic surgery type should be performed. Overall, the evidence supports that endoscopic diskectomy is of benefit to athletes with lumbar disk herniation. However, given the small number of studies with a paucity of prospective data collection, cautious interpretation of these findings is required.

 

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Conflict of Interest

None declared.

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Publikationsverlauf

Artikel online veröffentlicht:
23. Oktober 2025