Balancing neurological safety and patient psychology in percutaneous endoscopic lumbar discectomy: a comparison of three anesthetic modalities

Percutaneous endoscopic lumbar discectomy (PELD) is standard for lumbar disc herniation, but the optimal anesthesia—local (LA), general (GA), or epidural (EA)—remains controversial. This network meta-analysis systematically evaluated their comparative efficacy, safety, and patient-reported psychological outcomes. Six databases were comprehensively searched up to June 1, 2026, strictly for randomized controlled trials (RCTs) comparing LA, GA, and EA in PELD. Key endpoints included functional recovery (ODI), pain (VAS), operative time, complications, and positive anesthesia experience. A frequentist network meta-analysis was conducted, utilizing surface under the cumulative ranking (SUCRA) probabilities for treatment ranking. Furthermore, the certainty of evidence for all network estimates was formally assessed utilizing the Confidence in Network Meta-Analysis (CINeMA) framework. Seventeen RCTs comprising 1682 patients were included. The network geometry lacked a closed loop, relying on indirect comparisons between GA and EA. Compared to LA, EA significantly reduced early postoperative VAS (MD = − 0.83) and improved long-term ODI (MD = − 1.02), while enhancing the probability of a positive anesthesia experience (OR = 0.17). SUCRA rankings suggested EA's comparative advantage in reducing early pain (98.4%), accelerating functional recovery (98.0%), and shortening operative time (95.9%). LA was associated with a higher probability of mitigating intraoperative nerve root injury (SUCRA = 82.0%) but correlated with a higher risk of surgical fear (positive experience SUCRA = 0.3%). GA provided total immobility but prolonged postoperative bed rest (MD = 8.40 h vs. LA) and increased intraoperative blood loss. Per CINeMA, primary efficacy endpoints yielded moderate certainty, whereas secondary and safety outcomes had low to very low certainty due to indirectness and imprecision. Based on current indirect evidence, EA appears to provide a highly favorable balance for PELD, offering potential advantages in perioperative analgesia, accelerated functional recovery, and psychological protection. While LA remains the gold standard for high-risk cases requiring neurological feedback, it requires rigorous multimodal analgesic management to mitigate surgical fear. Given the low certainty of evidence for specific safety and secondary metrics, these probability rankings must be interpreted with caution, and future direct EA-versus-GA trials are warranted.