Introduction

The management of lumbar disc herniation (LDH) in the ultra-elderly population (≥ 85 years) is clinically challenging, primarily owing to a high burden of systemic comorbidities such as cardiovascular disease, diabetes, and chronic respiratory conditions. This age group, often classified as the “oldest-old,” represents the fastest-growing demographic segment in many countries and presents unique therapeutic challenges due to physiological frailty and reduced functional reserve. Conservative treatment is often ineffective, whereas traditional open surgery is limited by high risks associated with anesthesia and surgical trauma1,2. In comparison, percutaneous endoscopic transforaminal discectomy (PETD) under local anesthesia is a minimally invasive alternative. It potentially reduces systemic impact and facilitates real-time patient feedback during surgery3,4,5,6. However, evidence supporting its use in ultra-elderly (≥ 85 years) high-risk patients remains limited. Furthermore, the success of such interventions depends not only on the surgical technique but also on comprehensive perioperative management7. The involvement of a multidisciplinary team (MDT), encompassing specialists in spine surgery, anesthesiology, cardiology, pulmonology, endocrinology, and geriatrics, can optimize preoperative patient status and improve outcomes. Therefore, we hypothesized that, within an MDT framework, PETD performed under local anesthesia would provide superior pain relief and functional recovery, while maintaining an acceptable safety profile, compared with prolonged conservative treatment in carefully selected ultra-elderly patients. This study compared the efficacy and safety of MDT-supported local anesthesia PETD with those of conservative treatment in ultra-elderly high-risk patients with LDH using propensity score matching, with a focus on pain relief, functional improvement, and complication rates.

Materials and methods

Study design and ethics

This multicenter retrospective cohort study enrolled 64 symptomatic patients with LDH aged ≥ 85 years who underwent local anesthesia PETD between May 2022 and May 2024. The study protocol was approved by the Ethics Committee of the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine (Approval No.: 2025-060) and complied with the Declaration of Helsinki. Informed consent was obtained from all participants.

Patient selection and grouping

Inclusion criteria: Age ≥ 85 years; MRI-confirmed single-level LDH (L3/4, L4/5, or L5/S1); failure of conservative treatment for ≥ 3 weeks, defined by persistent severe radicular pain (VAS ≥ 7) and/or progressive neurological deficit; and presence of more than two systemic comorbidities.

Exclusion criteria: Spinal instability, cauda equina syndrome, severe cognitive impairment (MMSE < 15), infection, tumor, or spinal deformity.

Patients who received conservative treatment for LDH and were aged ≥ 85 years between January 2018 and April 2022 were identified from electronic medical records to form the historical control pool. Propensity scores were generated using 1:1 nearest-neighbor matching without replacement, with a caliper width set at 0.02. Matching variables included age, gender, body mass index (BMI), number of comorbidities, level of disc herniation, symptom duration, baseline Visual Analog Scale (VAS) scores for back and leg pain, Oswestry Disability Index (ODI), Clinical Frailty Scale (CFS), and Charlson Comorbidity Index (CCI). After matching, 64 patients were selected for the conservative treatment control group.

Conservative treatment protocol

The conservative treatment group received standardized non-surgical management. This included physical therapy (core muscle stabilization exercises twice weekly for 12 weeks, intermittent traction for 20 min per session, and physiotherapy modalities such as ultrasound or TENS), pharmacological therapy (non-steroidal anti-inflammatory drugs e.g., celecoxib 100 mg twice daily; neuropathic pain medication e.g., pregabalin 75 mg twice daily; muscle relaxants e.g., eperisone hydrochloride 50 mg three times daily), epidural steroid injection (administered under fluoroscopic guidance if leg pain VAS remained ≥ 7 after 6 weeks of therapy), activity modification, and health education. Treatment continued for at least 3 months, with crossover to surgery considered if symptoms worsened, defined as: (a) VAS for leg pain ≥ 7 after 3 months, (b) progressive motor or sensory deficit on neurological examination, or (c) inability to perform basic activities of daily living despite multimodal management.

MDT perioperative management protocol

All surgical patients were managed by an MDT comprising specialists in spine surgery, anesthesiology, cardiology, pulmonology, endocrinology, and geriatrics. Preoperative optimization, intraoperative monitoring, and postoperative rehabilitation were performed in accordance with standardized protocols (Table 1).

Table 1 Multidisciplinary team (MDT) perioperative management protocol and key performance Indicators.
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Surgical technique and anesthesia management

Patients were placed in the prone position. Premedication included intravenous midazolam (1–2 mg), with dosing adjusted for renal and hepatic function. Intraoperative sedation with a propofol infusion (10–30 µg/kg/min) was administered in 18.8% (12/64) of patients to alleviate discomfort, with no episodes of respiratory depression. For local anesthesia, 1% lidocaine was administered via layered infiltration (skin and subcutaneous tissue: 10 mL; facet joint capsule: 5 mL; perineural region of the nerve root in the foramen: 3 mL (total dose ≤ 200 mg)). Intraoperative patient movement or discomfort requiring additional local anesthetic occurred in 9.4% (6/64) of cases, and no patient required conversion to general anesthesia. The target level was identified using C-arm X-ray fluoroscopy. The puncture point was located 12–15 cm from the midline, with the needle angled at 15–25° to the horizontal plane. Fluoroscopy was used to confirm the position of the needle tip adjacent to the medial pedicle wall in the anteroposterior view and superior to the posterior disc margin in the lateral view. A 10 mm skin incision was made. Access was dilated using sequential dilators. Foraminoplasty, potentially involving partial facetectomy, was performed using a reamer if necessary. A working cannula was inserted, and the endoscope was installed. Under endoscopic visualization, the herniated disc fragment was identified and removed using pituitary forceps. The endoscope was maneuvered to explore and release the nerve root. After adequate decompression and absence of active bleeding were confirmed, the endoscope and working cannula were removed. The incision was then closed with a simple interrupted suture. A sterile dressing was applied to complete the procedure (Fig. 1).

Fig. 1
Fig. 1
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Percutaneous endoscopic transforaminal discectomy (PETD) was performed on an 88-year-old male patient with L4-L5 disc herniation. (A) Preoperative magnetic resonance image indicating L4-L5 disc herniation (arrow). (B) Intraoperative anteroposterior radiograph demonstrating the position of the working cannula. (C) Intraoperative lateral radiograph confirming the placement of the working cannula at the posterosuperior margin of the vertebral body. (D) Postoperative magnetic resonance image revealing a substantial reduction of the L4-L5 disc herniation (arrow). (E) Operative working cannula placed. (F) Intraoperative endoscopic view illustrating the nerve root (arrow)and intervertebral space (triangle).

Outcome measures

The primary outcome measures included VAS scores for back and leg pain and ODI scores assessed preoperatively at 1 day and 3 months, postoperatively at 1 year, and at the final follow-up. Secondary outcomes included the modified Macnab criteria, complication rates, and MDT management efficiency indicators (e.g., time to first ambulation and hospital stay). Complications were systematically recorded and included surgical site infection, dural tear, nerve injury, hematoma, cardiovascular events, pulmonary complications, delirium, and exacerbation of pre-existing medical conditions. Follow-up duration was documented for all patients.

Statistical analysis

Statistical analyses were performed using SPSS 26.0. Continuous data were compared using a Student’s t-test or Mann-Whitney U test. Categorical data were compared using the Chi-square test or Fisher’s exact test. To account for potential confounders, multivariate logistic regression was performed for the Macnab outcome (excellent/good vs. fair/poor), with treatment group, CFS, CCI, baseline VAS, and age entered as covariates. Linear mixed models were used to analyze repeated VAS and ODI measures over time. Effect sizes were reported as odds ratios (OR) with 95% confidence intervals (CI) for categorical outcomes and as Cohen’s d for continuous outcomes. A P-value < 0.05 was considered statistically significant.

Results

Baseline characteristics

This study included 64 ultra-elderly high-risk patients with LDH who underwent local anesthesia PETD. After propensity score matching, 64 patients with similar baseline characteristics were selected from the historical conservative treatment cohort to form the control group. Balance across matching covariates was satisfactory, with all standardized mean differences (SMDs) below 0.1 after matching. Before matching, significant differences were found between groups with respect to age, number of comorbidities, symptom duration, and baseline pain and disability scores (P < 0.05, Table 2). After matching, no statistically significant differences were observed between the two groups with respect to age, gender, BMI, number of comorbidities, involved level, symptom duration, baseline back pain VAS, leg pain VAS, ODI scores, CFS, and CCI (P > 0.05, SMD < 0.1). This indicated successful matching and balanced baselines (Table 3).

Table 2 Comparison of baseline characteristics between groups before propensity score Matching.
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Table 3 Comparison of baseline characteristics between groups after propensity score Matching.
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Efficacy analysis

Postoperative follow-up revealed that the PETD group had significantly lower back pain VAS, leg pain VAS, and ODI scores at both 3 months and 1 year postoperatively than the conservative treatment group (P < 0.01, Table 4). Linear mixed-effects model analysis confirmed a significant group-by-time interaction (P < 0.001), with larger improvement slopes in the PETD group. At the final follow-up, the excellent/good rate according to the modified Macnab criteria was 95.31% in the PETD group, which was significantly higher than the rate in the conservative group (31.25%) (P < 0.05). Multivariate logistic regression further showed that treatment was independently associated with an excellent/good Macnab outcome (OR = 25.6, 95% CI 8.4–78.1, P < 0.001) after adjusting for CFS, CCI, and baseline pain scores. In the conservative treatment group, 28.13% (18/64) of patients eventually crossed over to surgery owing to persistent or worsening symptoms, whereas in the PETD group, no patient required reoperation (Table 5).

Table 4 Comparison of efficacy outcomes between groups over time (Mean ± SD).
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Table 5 Comparison of clinical outcomes and safety at final Follow-up.
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Safety and MDT management efficiency indicators

Under MDT-guided perioperative management, 90.6% (58/64) of patients received preoperative medication optimization. The mean preoperative preparation time was 2.28 ± 0.45 days. Patients were ambulated for the first time at 3.40 ± 0.88 h postoperatively. The mean postoperative hospital stay was 2.34 ± 0.47 days. No serious surgery- or anesthesia-related complications were observed. Specifically, there were no instances of surgical site infection, dural tear, nerve injury, hematoma, cardiovascular events, pulmonary complications, or postoperative delirium. In addition, no exacerbation of pre-existing medical conditions occurred during the perioperative period. The mean follow-up duration was 14.2 ± 3.1 months in the PETD group and 13.8 ± 4.2 months in the conservative group (Table 6).

Table 6 Perioperative management efficiency indicators and safety Outcomes.
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Discussion

Key advantages of the MDT-Local anesthesia PETD protocol

The excellent outcomes (Macnab excellent/good rate 95.31%) of the protocol could be attributed to the synergistic effect of the minimally invasive technique used (PETD) and refined perioperative management (MDT). For ultra-elderly high-risk patients, the therapeutic conflict lies between the urgent need for surgical decompression and the fragile physiological reserve of the patients. This protocol successfully addresses this conflict. Local anesthesia fundamentally avoids the systemic disturbances associated with general or neuraxial anesthesia, which is critical in patients aged ≥ 85 years who typically have markedly reduced cardiopulmonary reserve, impaired autonomic regulation, and heightened susceptibility to postoperative delirium and neurocognitive disorders8,9. Keeping the patient awake allows them to provide invaluable real-time neurological feedback, acting as a “natural monitor” to prevent nerve injury. This is crucial for ultra-elderly patients, who often have narrower foramina and less neurological redundancy, which increases procedural complexity10,11. Furthermore, local anesthesia mitigates risks associated with polypharmacy and drug-drug interactions, a common challenge in this population12. The fact that 90.6% of patients received preoperative medication optimization demonstrates that the MDT actively optimizes patients to the most suitable surgical state, transforming comorbidities from “contraindications” into “manageable factors”. This is fundamental to achieving the ultra-low complication rate and absence of comorbidity exacerbation.

Application of spinal endoscopy in the elderly: Advantages, Challenges, and evidence comparison

The evidence from this study supports the use of spinal endoscopic techniques in the ultra-elderly population. Compared to traditional open surgery, PETD exhibits pronounced minimally invasive advantages in this group: the incision required is only approximately 7 mm, which causes minimal tissue damage and reduces surgical trauma and stress response. Recent evidence supports that for patients with degenerative lumbar conditions without instability (e.g., spondylolisthesis or deformity), decompression alone provides equivalent clinical outcomes to decompression with fusion, while minimizing surgical morbidity such as operative time, blood loss, and length of hospital stay13. This is particularly relevant for medically frail elderly patients where minimizing physiological stress is paramount. Our findings align with this evidence-based approach, demonstrating that meaningful functional recovery can be achieved with percutaneous endoscopic discectomy (a decompression-only procedure) without fusion in selected ultra-elderly patients without spinal instability. Based on these advantages, patients were ambulated on average at 3.4 h postoperatively, and the average hospital stay was shortened to 2.3 days. This significantly reduced the risk of complications associated with prolonged bed rest in the elderly, such as pneumonia, deep vein thrombosis, and delirium14,15,16.With respect to clinical efficacy, the results of this study are comparable to those reported by Li et al.17for minimally invasive transforaminal lumbar interbody fusion in treating LDH, but PETD offers advantages in terms of the degree of surgical trauma. Compared to that in previous studies18,19, in this study, the applicable age range of spinal endoscopy was extended to ≥ 85 years (mean 89.1 years), confirming the feasibility and safety of the procedure in the ultra-elderly population. Therefore, we believe PETD is an important treatment option for ultra-elderly patients with LDH.

Positioning of Conservative treatment and reconsidering the timing of surgery

The high crossover rate to surgery (28.13%, 18/64) in the control group revealed that the excessive prolonging of conservative treatment may not be an optimal strategy for ultra-elderly patients with clear neurological compression symptoms. Subgroup analysis of crossover patients revealed higher baseline CFS scores and more severe leg pain, suggesting that frailty and symptom severity may predict failure of conservative treatment. The traditional “step-care” principle requires a more flexible approach in this population. Pathological processes in the ultra-elderly are often irreversible. Prolonged pain and disability can lead to a vicious cycle involving muscle atrophy, increased fall risk, and cognitive decline20,21. Therefore, the decision for surgery should be based on precise MDT assessment: if the responsible lesion is clear and short-term (e.g., 1–3 months), conservative treatment is ineffective. The MDT deems surgery to be safe, and more active intervention is considered to avoid functional decline and missing the window of opportunity for surgery owing to prolonged waiting. The findings of this study confirm that age and comorbidities should not be absolute contraindications to surgery after MDT optimization.

Limitations

This study has several limitations. First, the retrospective design is subject to inherent biases, including potential indication bias in treatment allocation. Second, the conservative and PETD cohorts were from different time periods (2018–2022 vs. 2022–2024), during which perioperative care protocols may have evolved, potentially influencing outcomes. Although propensity score matching was applied to reduce baseline confounding, residual and unmeasured temporal effects cannot be fully excluded. Third, despite the incorporation of the CFS and CCI, other frailty-related variables, such as detailed cognitive scores and nutritional status, were not consistently available. Fourth, although the study was multicenter, it was conducted within a single regional healthcare system, which may limit generalizability. Finally, long-term outcomes beyond 1 year, particularly re-herniation rates and functional decline, were not assessed and warrant future investigation.

Conclusion

Within an MDT-supported perioperative management framework, percutaneous endoscopic transforaminal discectomy under local anesthesia is a safe and effective treatment for ultra-elderly high-risk patients with lumbar disc herniation. It demonstrates superior mid-term outcomes compared to conservative treatment and facilitates rapid recovery.This effectively balances surgical efficacy with physiological frailty in the oldest-old population, supporting its applicability in routine clinical practice.