Full-endoscopic rhizotomy for degenerative lumbar facet joint syndrome: a systematic review and meta-analysis

Introduction

Lower back pain is one of the most common pain-generating conditions, affecting approximately 15% of the population (1). It is estimated that 15–45% of all lower back pain cases are caused by pathologies of the lumbar facet joint, with the nerve complex surrounding the lumbar facet joint’s synovial capsule widely believed to be a significant cause of pain when inflamed or irritated (2-3). The majority of facet joint nerve irritation can be attributed to degenerative changes such as osteoarthritis, thereby classifying these cases of back pain as degenerative facet joint syndrome (FJS). Current treatments for degenerative FJS include physical therapy, medial branch block, intra-articular steroid injections, rhizotomy, chemical neurolysis, cryo-neurolysis, and neurotomy (3).

Facet joint radiofrequency rhizotomy is a procedure that treats lower back pain by ablating the nerve fibers innervating the lumbar facet joint with radiofrequency energy (4). Multiple approaches for performing rhizotomies exist including percutaneous and endoscopic approaches, both of which have been proven to be effective in treating lower back pain caused by degenerative FJS (4). Full-endoscopic lumbar facet joint rhizotomy is a surgical procedure that ablates the medial branch of the dorsal rami of the spinal nerves using radiofrequency energy under visual navigation from a spinal endoscope (5). Jeong et al.’s study published in 2014 is the first to report the effectiveness of this technique in treating chronic lower back pain (5). Since then, multiple studies have demonstrated the efficacy of the full-endoscopic lumbar facet joint rhizotomy technique in relieving the pain and reducing disability through quantitative metrics such as the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) (5-18).

This systematic review and meta-analysis aim to comprehensively analyze the efficacy and safety of full-endoscopic rhizotomy in degenerative lumbar FJS through statistical analysis of published results and analyzing the unique quantitative findings from each study. We present this article in accordance with the PRISMA reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-199/rc).

Methods

Search strategy

An extensive literature search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria was performed on the PubMed and Scopus databases to compile research articles reporting the efficacy of full-endoscopic lumbar rhizotomy techniques in treating degenerative FJS available between January 2000 and December 2025, with the last search being conducted on December 20 2025. The specific search strategy utilized Boolean operators (AND, OR) to combine medical subject headings (MeSH) terms and free-text keywords. The exact search string employed for PubMed was: (“Facet Joint”[MeSH] OR “Zygapophyseal joint” OR “Lumbar facet”) AND (“Rhizotomy”[MeSH] OR “Denervation” OR “Neurotomy”) AND (“Endoscopic” OR “Full-endoscopic”). Similar logic was adapted for the Scopus database. Results were limited by specific filters: articles published in the English language, human subjects, and full-text availability. Both MeSH terms and free-text terms were used to enhance search sensitivity. Additionally, a manual review of the reference lists of relevant studies was performed to maximize search coverage.

Study selection

The study selection process was independently performed by two authors (W.L. and P.S.). Initially, titles and abstracts of all identified studies were screened to exclude irrelevant studies. Full-text versions of potentially eligible studies were then retrieved and assessed in detail to determine whether they met the inclusion or exclusion criteria. In cases where discrepancies arose between the two reviewers regarding study eligibility, consensus was reached through discussion. If disagreements still persisted after discussion, a third reviewer was consulted to resolve any remaining disputes.

Inclusion and exclusion criteria

The inclusion and exclusion criteria for this study are as follows: the study quantitatively reports a comparison of preoperative and postoperative neurological and disability status after full-endoscopic lumbar rhizotomy. The exclusion criteria exclude cases where other interventions were performed on the full-endoscopic lumbar rhizotomy cohort during the follow-up period after the endoscopic rhizotomy procedure. Fourteen studies were included in the final analysis (5-18). Secondary studies, including literature reviews and meta-analyses, were excluded from the analysis due to overlapping data with the primary studies included. Conference abstracts were excluded from the analysis.

Data extraction

Two independent reviewers screened the titles and abstracts of all identified studies. Full-text articles of potentially eligible studies were retrieved and reviewed in detail. Any reviewer discrepancies were resolved by consensus or consulting a third reviewer. Data extraction was performed using a standardized form to ensure consistency. Initial data extraction compiled the basic information of each study such as the authors, publication year, institution, number of participants and reported neurological and disability metrics.

Statistical analysis

Statistical analysis was performed using Microsoft Excel version 2511. Effect size estimation, standard error calculation, forest plot generation, heterogeneity assessment, and publication bias evaluation were conducted using the Meta-Essentials workbook (19).

Risk of bias assessment

Risk of bias was evaluated for all included studies to assess the internal validity of the evidence. Two reviewers conducted the assessment independently using appropriate tools based on the study design. Non-randomized studies were appraised using the Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I) tool (20), while randomized controlled trials (RCTs) were assessed using the Cochrane RoB 2.0 tool (21). Discrepancies in assessment were resolved through discussion and consensus.

Results

Study selection

A total of 79 studies were initially identified. After removing 24 duplicates, a total of 55 potentially relevant studies were reviewed. Upon full text review of the remaining studies, 14 peer-reviewed research articles comparing the preoperative and postoperative neurological and disability-related metrics were included in the final analysis (5-18). The PRISMA flow diagram summarizing the study selection process is presented in Figure 1.

Figure 1 PRISMA flow diagram of the study. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Study characteristics

The 14 included studies were published between 2014 and 2024 and involved a total of 1,467 patients. Study designs included retrospective cohorts, prospective cohorts, matched comparisons, and RCTs. Sample sizes ranged from four to 450 patients. The studies evaluated outcomes such as VAS, ODI, pain relief percentage, patient satisfaction, and complications. A summary of the study characteristics and demographics is provided in Table 1.

Risk of bias

Risk of bias was assessed using the ROBINS-I tool for non-randomized studies and RoB 2.0 for RCTs. Among the non-randomized studies, several were judged to have moderate risk of bias, with three studies rated as serious. Of the two RCTs, one demonstrated low risk across all domains, while the other had some concerns regarding randomization and adherence. Detailed risk of bias assessments are summarized using the ROBINS-I tool in Figure 2, and the RoB 2.0 tool in Figure 3.

Figure 2 Risk of bias assessment of the included non-randomized studies using the ROBINS-I tool. ROBINS-I, Risk Of Bias In Non-randomized Studies-of Interventions.

Figure 3 Risk of bias analysis using Cochrane’s RoB 2 Tool.

Clinical and surgical outcomes of systematic review and meta-analysis

This comprehensive review of 14 clinical studies highlights the growing evidence supporting the efficacy and safety of endoscopic rhizotomy and facet joint denervation for managing chronic low back pain attributed to facet joint pathology. Across various study designs—including RCTs, prospective cohorts, and retrospective analyses—endoscopic techniques consistently demonstrated significant improvements in pain scores (VAS, NRS) and functional outcomes (ODI, MacNab) with durable relief extending up to two years in many cases. Compared to conventional radiofrequency ablation (RFA), endoscopic approaches offered noninferior long-term results, greater precision through direct visualization, and reduced complication rates. Innovative techniques such as three-dimensional (3D) navigation-assisted endoscopic rhizotomy and selective joint capsule excision further enhanced outcomes, especially in anatomically complex or recurrent cases. Overall, these findings suggest that full-endoscopic denervation is a promising minimally invasive alternative to traditional methods, although limitations such as small sample sizes, short follow-up periods, and the need for advanced equipment remain challenges in broader clinical adoption. We present a comprehensive summary of 14 studies focusing on endoscopic rhizotomy or facet joint denervation for chronic low back pain in Table 2.

Improvement of clinical outcomes

The 14 papers reviewed in this meta-analysis compared preoperative and postoperative clinical outcomes using the VAS, ODI, patient satisfaction score, percentage of pain relief, numeric rating scale, pain reduction rate (PRR), successful treatment rate (STR), Odom’s Criteria, Global Impression of Change and Patient Global Assessment. Most papers reported clinically and statistically significant long-term improvements in pain and disability measurements. A random-effects model was used for all meta-analyses due to anticipated clinical and methodological heterogeneity among included studies.

Quantitative analysis of preoperative and postoperative VAS improvements

The VAS is a quantitative tool for patients to rate the severity of their pain (22). The studies reviewed in this meta-analysis utilized the VAS which records the patient’s self-reported pain severity with zero representing no pain experienced and 10 representing the worst pain that can possibly be experienced by the patient. This study compiled the preoperative and postoperative VAS improvements from 33 observations across nine studies (5-7,9,10,12,13,15,18). The summary effect represented a VAS improvement of −4.36 [95% confidence interval (CI) : −4.42 to −4.31] as presented in Figure 4. Heterogeneity of data was present across studies (Cochran’s Q: 2,794.70, I²: 98.93%, τ²: 3.64). Publication bias was visually assessed using a funnel plot as presented in Figure 5.

Figure 4 A forest plot compiling the preoperative and postoperative VAS score differences from 33 observations across 10 studies. The summary effect was −4.36 with a 95% CI between −4.42 and −4.31. CI, confidence interval; MBB, medial branch block; NAS, Numeric Analog Scale; PostOp, postoperative; PreOp, preoperative; SD, standard deviation; VAS, Visual Analogue Scale.

Figure 5 A funnel plot compiling the effect size of the VAS score differences from 33 observations across 10 studies. CES, corrected effect size; VAS, Visual Analogue Scale.

Quantitative analysis of preoperative and postoperative ODI score improvements

The ODI is one of the most commonly used condition-specific outcome measures for spinal disorders (23). The index comprises of 10 items representing everyday activities of daily living, pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex (if applicable), social and travel. Each item consists of six statements which are numerically represented from zero to five. A score of zero indicates minimal disability and a score of five indicates the greatest disability. The total score is then calculated as a percentage with 0% indicating no disability and 100% indicating the highest level of disability possible. This study quantitatively analyzed the preoperative and postoperative ODI score improvements for 42 observations across nine studies, covering a total of 381 patients (5,7,9,11,12,14,16-18). The summary effect was −32.32 (95% CI: −32.84 to −31.80) as presented in Figure 6.

Figure 6 A forest plot compiling the preoperative and postoperative ODI score differences from 42 observations across 9 studies. The summary effect was −32.32 with a 95% CI between −32.84 and −31.80. CI, confidence interval; ODI, Oswestry Disability Index; PostOp, postoperative; PreOp, preoperative; SD, standard deviation.

Operation time

Ten out of 14 studies covered in this meta-analysis reported the mean operation time for endoscopic rhizotomy, with a total of 357 patients covered in these 10 studies. The mean operation time weighted by the number of participants in each study is 46.36 minutes (range, 20–75.89 minutes) (5,11,13,15-18).

Complications and safety

No study reported severe or permanent complications, with a few studies reporting minor complications. Yeung et al.’s study reported some patients experiencing pain under local anesthesia caused by inadvertent placement of the thermal probe ventral to the transverse process (7). From a surgical technique perspective, Yeung et al.’s study mentioned that endoscopic rhizotomy has no complications if proper protocol is followed, and the RF probe does not get ventral to the transverse process plane and does not penetrate the inter-transverse ligament (7). Walter et al.’s study published in 2018 reported that no single complication occurred during the endoscopic intervention itself, and the rate of complication was 1.1% with failed suture (12). Xue et al.’s study reported that the incidence of complications (lack of skin sensation, analgesia) in the endoscopic RFA group was significantly less than that in the control group which underwent traditional percutaneous RFA (6.67% vs. 30%, P<0.05) (10).

Recurrence of symptoms and reoperation

The majority of studies reported low recurrence of symptoms which correlates with the significant improvements in VAS and ODI scores. Most notably, Walter et al.’s study reported that 17 (12%) of patients required reoperation due to recurrence of symptoms, however, no major complications were reported in this study (12). Further reporting of recurrence data is important to assess the long term efficacy of endoscopic lumbar facet joint rhizotomy.

Discussion

This systematic review and meta-analysis aimed to synthesize the current evidence on the efficacy and safety of full-endoscopic rhizotomy in treating degenerative lumbar FJS, a common source of chronic axial low back pain. Our pooled analysis of 14 studies involving 1,467 patients demonstrated significant improvements in pain and functional outcomes, with a mean reduction of 4.36 points on the VAS and a 32.32-point reduction on the ODI. These findings underscore the clinical utility of full-endoscopic rhizotomy as a minimally invasive and effective alternative for patients with refractory facet-mediated low back pain. A comparison of our study’s quantitative analysis compared with multiple systematic reviews, meta-analyses and Cochrane reviews showed that endoscopic rhizotomy provided much greater pain and disability relief than percutaneous rhizotomy performed under fluoroscopic navigation (24-27). The VAS score improvements for percutaneous rhizotomy under fluoroscopic navigation were reported in Maas et al.’s Cochrane review as −1.5 (95% CI: −2.3 to −0.7) at one month, −0.7 (95% CI: −2.3 to 0.8) at 1–6 months and −0.7 (95% CI: −1.5 to 0.1) at more than 6 months. The ODI score improvements in this same Cochrane review were reported as −5.5 (95% CI: −8.7 to −2.4) at one month and −3.7 (95% CI: −6.9 to −0.5) at more than six months (27). Two studies in our review reported that endoscopic rhizotomy had a longer operation time than the traditional percutaneous rhizotomy performed under fluoroscopic navigation (16,18). Du et al.’s study reported that endoscopic rhizotomy took 25.5 minutes longer than the percutaneous approach (61.9±12.9 vs. 36.4±7.6) (14). Chen et al.’s study reported that endoscopic rhizotomy took 22.67 minutes longer than the percutaneous approach (61.75±23.55 vs. 39.08±14.05) (16).

The clinical burden of FJS continues to rise with the aging population. Full-endoscopic rhizotomy, unlike traditional percutaneous RFA, enables direct visualization of the medial branches of the dorsal rami and the facet joint capsule, allowing precise denervation while minimizing the risk of injury to surrounding structures. In the reviewed studies, the endoscopic approach consistently resulted in greater pain relief, lower recurrence rates, and improved functional recovery compared to conventional fluoroscopy-guided RFA. Importantly, no permanent or serious complications were reported. Minor adverse events such as transient numbness, intraoperative discomfort, and failed sutures were rare and manageable. From a practical perspective, full-endoscopic rhizotomy can be performed under local anesthesia with conscious sedation, making it suitable for elderly or medically complex patients. However, it requires a steeper learning curve and longer operative time due to anatomical dissection and scope handling. As endoscopic systems and navigation tools continue to evolve, procedural efficiency and surgeon familiarity are expected to improve. Despite its advantages, the technique is currently limited to specialized centers due to the need for endoscopic equipment, trained personnel, and access to intraoperative imaging or navigation systems. Broader adoption will depend on dedicated training programs, economic evaluation, and institutional support.

Limitations of this study, while our analysis provides strong evidence of clinical efficacy, it is important to acknowledge limitations. A significant proportion of the included studies were observational, with moderate to serious risk of bias related to patient selection, confounding variables, and outcome measurement. Furthermore, there was variability in surgical techniques (e.g., transforaminal vs. interlaminar approach, joint capsule and articular process excision in Tang et al.’s study) (18), mixing of sacroiliac joint and lumbar data, potential for publication bias, nerve targeting strategy, and follow-up duration, which may influence outcomes. Our pooled VAS and ODI effects may be inflated by heterogeneity of data reporting, dataset mixing, scaling differences, wide variation of follow-up intervals and incomplete data reporting across different studies. Incidences of complication and recurrence may be underreported in some studies. Additionally, most studies lacked long-term data beyond 24 months, limiting assessment of recurrence or sustained effectiveness.

Future directions of full-endoscopic rhizotomy as a standard treatment modality, future research should focus on multicenter RCTs comparing endoscopic rhizotomy with conventional RFA, cooled RFA, chemical neurolysis, and intra-articular injections. The development of standardized operative protocols, including guidance on approach selection, ablation parameters, and verification of denervation success, will enhance reproducibility and facilitate training across institutions. Moreover, integration of navigation-assisted systems and artificial intelligence-guided targeting may improve accuracy and shorten the learning curve. From a clinical practice standpoint, future studies should evaluate long-term outcomes, cost-effectiveness, and health-related quality of life measures, including patient reported outcome measures. Establishing outcome benchmarks and predictors of treatment success (e.g., imaging biomarkers or response to diagnostic medial branch block) could improve patient selection and personalize treatment strategies. Finally, the incorporation of full-endoscopic rhizotomy into stepwise management algorithms for chronic low back pain may enhance multidisciplinary decision-making and reduce opioid dependency or progression to fusion surgery.

Conclusions

This systematic literature review and meta-analysis demonstrates that endoscopic rhizotomy is a safe and highly effective method for treating lumbar FJS. When compared to percutaneous rhizotomy performed under fluoroscopic navigation, endoscopic rhizotomy provides greater relief of pain and disability which is better sustained over a longer duration. At present, endoscopic rhizotomy has a significantly longer operation time than percutaneous rhizotomy. However, this operation time can be reduced with greater experience and familiarity in performing endoscopic rhizotomy procedures. Future primary studies can focus on developing an effective evidence-backed technique for increasing the efficacy and safety of endoscopic rhizotomy along with guidelines to measure and ensure the adequacy of denervation. Future secondary studies can focus on comparing endoscopic rhizotomy’s efficacy and safety to other techniques for treating lumbar FJS such as percutaneous rhizotomy and facet joint steroid injections.

Acknowledgments

The authors would like to thank the Thailand Science Research and Innovation Fund and the University of Phayao (Fundamental Fund 2026, Grant No. 2253/2568).

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-199/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-199/prf

Funding: This study was supported by the Thailand Science Research and Innovation Fund and the University of Phayao (Fundamental Fund 2026, Grant No. 2253/2568).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-199/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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