Comprehensive identification of risk factors for recurrence after percutaneous endoscopic lumbar discectomy: a systematic review and meta-analysis

Objective: This meta-analysis aimed to identify risk factors associated with postoperative recurrence following Percutaneous Endoscopic Lumbar Discectomy (PELD) for Lumbar Disc Herniation (LDH). Methods: We systematically searched PubMed, the Cochrane Library, EMbase, CNKI, WanFang, and VIP databases for case-control and cohort studies investigating risk factors for recurrence after PELD, from their inception until August 30, 2025. Two reviewers independently extracted data and assessed the methodological quality of the included studies using the Newcastle-Ottawa Scale (NOS). Meta-analysis was performed using Stata 12.0 software to calculate the pooled odds ratios (OR) and 95% confidence intervals (CI) for each potential factor. Results: A total of 39 case-control studies, involving 14,454 patients, were included. The overall postoperative recurrence rate was 11.0% (95% CI: 9.1%-13.0%). Factors significantly associated with an increased risk of recurrence included: Modic changes (OR = 1.74, 95% CI: 1.25-2.23), particularly type II Modic changes (OR = 1.87, 95% CI: 1.02-2.72); diabetes mellitus (OR = 2.34, 95% CI: 1.52-3.59); smoking (OR = 2.02, 95% CI: 1.27-3.21); intraoperative annulus fibrosus rupture (OR = 2.40, 95% CI: 1.28-4.49); greater sagittal range of motion (SROM) (OR = 2.00, 95% CI: 1.58-2.53); higher body mass index (BMI) (OR = 1.30, 95% CI: 1.18-1.42); advanced age (OR = 1.21, 95% CI: 1.12-1.30); and high-intensity postoperative activity (OR = 1.83, 95% CI: 1.23-2.44). Among the herniation types, sequestrated disc herniation was associated with the highest recurrence risk. No significant correlation was found between the Pfirrmann grading system and recurrence risk (OR = 1.28, 95% CI: 0.95-1.60). Conclusion: The results of this meta-analysis indicate that recurrence after PELD for LDH is associated with a range of factors. Significant independent patient-related risk factors include advanced age, higher BMI, smoking, diabetes, and the presence of Modic changes (especially type II). Regarding surgical factors, intraoperative annulus fibrosus rupture significantly increases the risk of recurrence. Postoperatively, engaging in high-intensity activities too early or having a greater lumbar SROM also markedly elevates the probability of recurrence.