Endoscope-assisted ACDF reduces complication rates and blood loss but increases operative timeEndoscope-assisted surgery shows fewer complications for cervical disease

BackgroundEndoscope-assisted anterior cervical discectomy and fusion (EA-ACDF) has been introduced as a modified technique for the treatment of degenerative cervical disease, but its comparative efficacy and safety relative to conventional ACDF (CA-ACDF) remain uncertain. This systematic review and meta-analysis aimed to compare EA-ACDF with CA-ACDF for single-level degenerative cervical disease.MethodsPubMed, Embase, Web of Science, the Cochrane Library, CNKI, WanFang, VIP, and SinoMed were searched from inception through September 7, 2026. Comparative studies of EA-ACDF vs. CA-ACDF were included. Random-effects meta-analyses were performed. Methodological quality was assessed using the Newcastle–Ottawa Scale, and certainty of evidence was evaluated using GRADE.ResultsEleven retrospective comparative studies involving 755 patients were included. Compared with CA-ACDF, EA-ACDF was associated with longer operative time (MD = 17.31 min, 95% CI 11.38–23.23), but lower intraoperative blood loss (MD = −17.31 mL, 95% CI −24.38 to −10.25), postoperative drainage volume (MD = −10.97 mL, 95% CI −16.98 to −4.96), length of hospital stay (MD = −0.67 days, 95% CI −1.16 to −0.17), and overall complication rate (RR = 0.44, 95% CI 0.25–0.78). No significant between-group differences were observed in final Japanese Orthopaedic Association score, Neck Disability Index, visual analogue scale score, cervical lordosis, or fusion rate. The certainty of evidence ranged from low to very low.ConclusionEA-ACDF may offer modest perioperative advantages at the cost of longer operative time, while short- to mid-term clinical, radiographic, and fusion outcomes appear broadly similar. Current evidence does not establish clinical superiority.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420251123475, identifier CRD420251123475.