Comparative efficacy and safety of unilateral biportal endoscopic posterior cervical foraminotomy versus anterior cervical discectomy and fusion for single-level cervical radiculopathy: a retrospective cohort study

Introduction

Lateral cervical disc herniation or osteophytes in the neural foramen frequently lead to a set of symptoms and manifestations of radicular arm pain that is due to cervical degenerative disc disease (1). For most patients, symptoms can be alleviated with medication or conservative physical therapies (2). Treating radiculopathy with Anterior cervical discectomy and fusion (ACDF), a surgical technique regarded as the gold standard, has been reported to be a secure and effective method for achieving long-term clinical and radiological results (3). According to the North American Spine Society (NASS) evidence-based guidelines, both anterior and posterior surgical approaches are considered appropriate for selected patients with cervical radiculopathy after failure of conservative treatment, with surgical decision-making tailored to individual pathology and clinical presentation (4).

Despite its effectiveness, ACDF is associated with several limitations, including loss of segmental motion, adjacent segment degeneration (ASD), and approach-related complications (5). To address these concerns, motion-preserving and minimally invasive posterior techniques have gained increasing attention. Unilateral biportal endoscopy (UBE), first introduced by De Antoni for lumbar applications (6), has recently been adapted for cervical spine surgery. This technique enables targeted decompression while preserving surrounding structures and cervical mobility, aligning with the growing trend toward minimally invasive and motion-preserving strategies (7-9).

Importantly, the current literature should be interpreted with precision. While earlier studies suggested a lack of direct comparative evidence between UBE and ACDF, recent investigations have begun to address this gap. Emerging evidence now includes prospective randomized controlled trials and comparative clinical studies evaluating UBE against ACDF, demonstrating comparable clinical outcomes with potential advantages in recovery and motion preservation (10,11). However, the overall body of evidence remains limited, relatively recent, and heterogeneous, particularly for strictly defined single-level cervical radiculopathy (12-17).

Although randomized controlled trials are considered the gold standard for assessing efficacy and safety, they are often limited by strict inclusion criteria and controlled environments. In contrast, real-world retrospective cohort studies can provide valuable complementary evidence by reflecting routine clinical practice, broader patient populations, and variability in surgical decision-making. Such studies are particularly useful for evaluating perioperative outcomes, complication profiles, functional recovery, and return-to-work metrics. Therefore, the present retrospective cohort study aims to compare the clinical efficacy, safety, and motion-preservation outcomes of UBE and ACDF in patients with single-level cervical radiculopathy, thereby providing additional real-world evidence to the evolving literature (10). We present this article in accordance with the STROBE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-2026-1-0023/rc).

Methods

Patient population

The Institutional Review Board of Norinco General Hospital has approved this retrospective controlled study (No. 202305130818000349884). All participants provided written informed consent. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Between February 2020 and November 2024, 141 patients underwent surgical treatment for single-level unilateral intractable radiculopathy at our center. Patients were consecutively identified from institutional surgical records to minimize selection bias. The choice of surgical procedure (ACDF or UBE) was based on surgeon preference, imaging findings, and patient-specific clinical factors. No formal sample size calculation was performed due to the retrospective nature of the study; instead, all eligible patients within the study period were included to maximize statistical power.

Inclusion and exclusion criteria

The inclusion criteria for patients were as follows: (I) unilateral foramen stenosis along with cervical paracentral disc herniation (including soft disc herniations and osteophytes or hard disc) was detected by computerized tomography (CT) and magnetic resonance imaging (MRI), and this finding was in line with symptoms like unilateral upper limb pain; (II) patients who underwent ACDF or UBE because of single-level cervical radiculopathy; (III) systematic conservative treatment for at least six weeks was unsuccessful. Baseline clinical variables, including age, sex, body mass index (BMI), smoking status, American Society of Anesthesiologists (ASA) physical status, Preop-Visual Analog Scale (VAS), Neck Disability Index (NDI), range of motion (ROM), symptom duration, and affected level, were collected from medical records for comparability assessment.

The following were the exclusion criteria: (I) patients who had severe cervical segmental instability, spondylolisthesis, or severe kyphosis were excluded; (II) there were patients showing cervical spondylosis myelopathy, spinal tumor, and ossification of the posterior longitudinal ligament; (III) the follow-up time was less than 12 months; (IV) patients with incomplete radiological data.

Follow-up evaluations were conducted at 5 days, 3 months, and 12 months after the surgical procedure. A questionnaire was completed by patients through outpatient and telephone follow-ups. The intensity of arm and neck pain was evaluated using the VAS. Functional status was measured by means of the NDI. Two observers independently carried out the X-ray inspection. To evaluate the efficacy, the cervical ROM on dynamic (flexion/extension) plain cervical spine radiographs between C2 and C7 was compared. Measurements were taken before the operation and at 5 days, 3 months, and 12 months after the operation. Every complication was noted down. All outcome assessments were performed according to a standardized follow-up protocol.

The type of disc location

To ensure the efficacy and safety of the surgical operation, it is essential to be aware of the position and type of intervertebral disc herniation. When making decisions regarding specific surgical procedures, it is beneficial to categorize the disc herniation into the following types: central disc herniation, paracentral disc herniation, and foraminal disc herniation as observed on the MRI view (Figure 1). When observed on the CT scan, disc herniation in terms of location can be divided into two main types: isolated disc herniation (either soft disc or ruptured disc material) and osteophytes (hard disc or disc osteophytes) (18,19).

Figure 1 Types of soft disc herniations. (A) Central disc herniation. (B) Paracentral disc herniation. (C) Foraminal disc herniation. Red arrows indicate the location of disc herniation.

Surgical techniques

A single experienced surgeon performed all the surgical procedures. The surgical approach bears resemblance to those described in the literature for ACDF (Smith-Robinson method) (20). However, the process of the UBE surgery was as follows. Under general anesthesia, the patient was positioned in a prone posture with the chest elevated. The horseshoe headrest was used to adjust the operating table until the patient’s cervical curvature was straight and parallel to the ground (21).

Under fluoroscopy, a skin incision is made above the medial junction of the upper and lower facet joint (V-point). Under the view of the endoscope (Stryker, 30°, 4 mm), remove the soft tissue surrounding the V-point. The lower part of the upper-level lamina, the upper part of the lower-level lamina, and the facet joint are successively drilled out. Initially, a high-speed pneumatic drill at 15° with a 2- or 3-mm diameter is used to minimize bone tissue resection and better safeguard cervical spine stability. A tiny keyhole is formed between the lateral one-third of the lamina and the medial facet. Secondly, a high-speed drill equipped with a protective sheath drill bit is commonly used around the nerve root to ensure both effectiveness and safety. Once the decompression of bone tissue has been sufficiently finished, a blunt dissector is subsequently employed to carefully maneuver the nerve root so as to eliminate the soft fragment of the herniated disc while visualizing the nerve (Figure 2). However, in cases where patients present with an osteophyte complex, more meticulous removal may be necessary. This could be achieved by utilizing a high-speed drill equipped with a protective sheath drill bit, along with a variety of angles. When dealing with degenerative neural foramina narrowing that doesn’t involve a fragmented disk or an osteophyte complex, bony decompression of the lower part of the anterior pedicle was surely carried out. This was achieved by using a high-speed drill equipped with a protective sheath and drill bit through the foramina (Figure 3).

Figure 2 Case 1: cervical spondylosis radiculopathy (C5/6, right, isolated soft disc herniation). (A) T2-weighted cervical sagittal MRI showing soft disc herniation on the C5/C6 level. (B) T2-weighted cervical axial MRI showing soft disc herniation on the right side. (C) The nucleus pulposus tissue is located above the nerve root. (D) The nucleus pulposus tissue is located below the nerve root. (E) Complete removal of the nucleus pulposus tissue that compresses the nerve root. (F) Coronal CT scan images revealed the partial defect of the right lamina after UBE. (G) T2-weighted cervical axial MRI, the soft disc herniation has been removed) T2-weighted cervical sagittal MRI, the soft disc herniation has been removed. (H) T2-weighted cervical sagittal MRI, the soft disc herniation has been removed. Red arrows indicate the soft disc herniation (A,B), nucleus pulposus tissue (C,D), compressed nerve root (E), and postoperative decompressed regions(F-H). CT, computerized tomography; MRI, magnetic resonance imaging; UBE, unilateral biportal endoscopy.

Figure 3 Case 2: cervical spondylosis radiculopathy (C5/6, left, disc osteophytes). (A,B) The MRI images showed herniation of the intervertebral disc in the C5/6 gap before the operation. (C) Axial CT image showed an osteophyte causing spinal root compression (arrow). (D,E) With the high-speed drill with the protective sheath drill-bit, the foramina were drilled through. (F) Adequate decompression of nerve roots. (G) After the UBE procedure, the MRI images showed enlargement of the lateral recess. (H) Axial CT scan images revealed the partial defect of the left lamina after UBE. Red arrows indicate disc herniation (A,B), osteophyte compression (C), decompression sites (D-F), and postoperative decompressed regions (G,H). CT, computerized tomography; MRI, magnetic resonance imaging; UBE, unilateral biportal endoscopy.

It was challenging to carry out operations on degenerative neural foraminal narrowing and osteophyte complex disc herniation. Conversely, it was relatively easy to dissect and remove soft disc fragments that were compressing the exiting nerve. Consequently, a drill bit equipped with a protective sheath is effective when working around nerve roots. After the nerve has been decompressed from the medial side to the lateral side, a blunt nerve hook is frequently utilized under visualization to evaluate whether the foramen has been adequately decompressed.

Statistical analysis

To minimize selection bias, propensity score matching (PSM) was performed using a 1:1 nearest-neighbor algorithm based on a multivariable logistic regression model including age, sex, BMI, smoking status, ASA classification, Preop-VAS, NDI, ROM, symptom duration, operated level, and symptom side.

Covariate balance was assessed using standardized mean differences (SMDs), with an SMD <0.1 indicating adequate balance. Continuous variables were expressed as mean ± standard deviation and compared using the independent-samples t-test or Mann-Whitney U test, as appropriate. Categorical variables were compared using the Chi-squared test or Fisher’s exact test. Multivariable linear regression analyses were performed in both matched and full cohorts to adjust for potential confounders.

All analyses were conducted using R software (version 4.5.3; R Foundation for Statistical Computing, Vienna, Austria), with P values <0.05 considered statistically significant.

Results

A total of 141 patients were enrolled, of whom 6 were lost to follow-up, leaving 135 patients for analysis (ACDF, n=94; UBE, n=41). Following 1:1 PSM, 38 matched pairs (n=76) were included in the matched cohort (Figure 4). As shown in Figure 4, baseline covariate imbalance observed before matching was effectively reduced after matching, with all SMDs below 0.1, indicating satisfactory balance. The consistency of results between the full and propensity score-matched cohorts indicates that potential selection bias was effectively controlled, thereby supporting the robustness and reliability of the findings (Figure S1, Tables S1-S3).

Figure 4 Covariate balance before and after propensity score matching. ASA, American Society of Anesthesiologists; BMI, body mass index; NDI, Neck Disability Index; ROM, range of motion; VAS, Visual Analog Scale.

Postoperative clinical outcomes in the matched cohort are presented in Table 1. Both groups demonstrated significant improvement in pain and functional outcomes over time. The UBE group showed lower VAS scores at all postoperative time points; however, a statistically significant difference was observed only at postoperative day 5 (2.39±0.86 vs. 2.87±1.09, P=0.03), while no significant differences were found at 3 months (P=0.63) or 12 months (P=0.31).

Similarly, the UBE group exhibited better early functional recovery, as reflected by lower NDI scores at postoperative day 5 (13.95±2.77 vs. 16.24±2.26, P<0.001). However, the differences between groups were not statistically significant at later time points (P=0.53 at 3 months; P=0.79 at 12 months).

In contrast, cervical ROM was significantly greater in the UBE group at both 3 months and 12 months postoperatively (32.41±6.55 vs. 38.87±5.39 and 33.45±7.20 vs. 40.39±4.27, both P<0.001), indicating superior preservation of cervical mobility compared with ACDF. The most frequently operated levels were C5/6 and C6/7.

Both groups showed progressive improvement in pain and functional outcomes over time. The UBE group demonstrated significantly lower VAS and NDI scores at early postoperative time points, indicating faster recovery. In contrast, cervical ROM was significantly greater in the UBE group at later follow-up, suggesting better preservation of motion compared with ACDF.

The overall complication rate was higher in the ACDF group (17.0%, 16/94) than in the UBE group (4.9%, 2/41). In the ACDF group, complications included one postoperative death due to laryngeal edema with airway obstruction, one spinal cord injury, one wound infection, three nerve root injuries, five cases of poor wound healing, and five cases of wound hematoma. In addition, five cases of adjacent segment disease (ASD) were observed during follow-up, all of which required reoperation (Figure 5).

Figure 5 This is a case of cervical spondylosis radiculopathy caused by adjacent vertebral disease. Laminoplasty is required after 5 years. (A) T2-weighted cervical sagittal MRI showing soft disc herniation on the C3/C4 level. (B) Sagittal CT scan images revealed that C3/4 has fused. (C) After five years, the T2-weighted cervical MRI showed the occurrence of adjacent segment degeneration. (D,E) Sagittal CT and MRI of a unilateral posterior laminoplasty. Red arrows indicate the initial disc herniatio (A), adjacent segment degeneration (B,C), and postoperative decompressed regions after laminoplasty (D,E). CT, computerized tomography; MRI, magnetic resonance imaging.

In contrast, the UBE group had fewer complications, including one case of spinal cord injury and one case of cerebrospinal fluid leakage. Notably, one severe complication occurred in each group. The patient with spinal cord injury in the UBE group showed partial neurological recovery following conservative treatment, whereas the patient with laryngeal edema in the ACDF group died despite prompt airway management. No implant-related failures or surgery-related technical errors were identified in either group.

Multivariable regression analysis demonstrated that UBE was significantly associated with improved early postoperative pain and functional outcomes, as well as enhanced recovery, as reflected by shorter return-to-work time. Furthermore, UBE showed a significant advantage in preserving cervical ROM at mid- and long-term follow-up. These findings remained robust after adjustment for potential confounders (Figure 6).

Figure 6 Adjusted effects of UBE versus ACDF on clinical outcomes. ACDF, anterior cervical discectomy and fusion; CI, confidence interval; NDI, Neck Disability Index; Post3m, postoperative 3 months; Post12m, postoperative 12 months; ROM, range of motion; UBE, unilateral biportal endoscopy; VAS, Visual Analog Scale.

Discussion

ACDF is widely used for the treatment of anterior pathologies, including cervical stenosis, unilateral or bilateral foraminal stenosis, herniated discs (both soft and hard), instability, and cervical spondylosis. Among these indications, herniated discs are particularly common. However, biomechanical evidence suggests that fusion of a single cervical level may increase stress on adjacent levels, thereby elevating the risk of ASD (22,23).

Long-term studies confirm these concerns. The incidence of ASD after ACDF has been reported to be approximately 2.9%, rising to 25.6% over a 10-year follow-up period (24). In addition, approximately 11% of patients develop ASD 5 years postoperatively (25). In the present study, 5.3% (5/94) of patients in the ACDF group required reoperation due to ASD. This rate appears higher than that reported in previous studies (1.4%, 16/1,171); however, differences in study design, sample size, and follow-up duration should be considered when interpreting this comparison (26).

In comparison, minimally invasive posterior approaches such as UBE may reduce the likelihood of adjacent-level disc herniation by preserving motion at the operated segment. In our study, no patient in the UBE group required reoperation for ASD during the 1-year follow-up period. Similarly, Emami et al. reported an 8.7% reoperation rate over seven years after minimally invasive posterior cervical foraminotomy (27).

ACDF and UBE demonstrated distinct complication profiles in the present study. ACDF was associated with anterior approach-related complications, including one postoperative death caused by laryngeal edema with airway obstruction, highlighting the potential severity of airway-related complications following anterior cervical surgery. In contrast, UBE avoids direct manipulation of anterior cervical structures, but it is technically demanding and carries procedure-specific neurological risks, including spinal cord injury. Although the overall complication rate was lower in the UBE group, both procedures should be recognized as high-stakes interventions with different risk profiles (27,28). Additional benefits of UBE include a shorter hospital stay and an earlier return to work (29).

Different types of herniation guide the selection of surgical approaches. (I) Central disc herniation: ACDF remains the optimal approach. (II) Paracentral or foraminal disc herniation (≤50% of facet joint): UBE is preferred. (III) Foraminal disc herniation exceeding 50% of facet joint or with osteophytes: Higher risk of recurrence, incomplete decompression, or residual pathology, requiring careful consideration (18,30).

This stratification ensures appropriate decompression while minimizing structural compromise. After flavum ligament removal, the nerve root and lateral dural sac are visualized, and bony decompression is performed using a high-speed drill with a protective sheath. Soft disc fragments are removed under direct visualization using micro hooks, whereas foraminal stenosis requires careful assessment with a 2–3 mm diamond burr (31). Importantly facet joint removal should not exceed 50%, as excessive resection may cause cervical instability (32,33).

Extensive case series demonstrate favorable outcomes for posterior-lateral foraminotomy techniques. Henderson et al. reported that 91.5% of 736 consecutively treated patients achieved good or excellent results, regardless of whether they had soft or hard disc pathology (34). Krupp et al. found superior outcomes for soft discs compared to hard discs (35), whereas Woertgen et al. noted that bony foraminal stenosis was associated with less favorable results (34).

Within UBE patients with over one-year follow-up, short-term relief is better for soft disc herniation than for bony foraminal stenosis. However, radiating pain gradually improves in the bony stenosis group over time, likely reflecting the duration and degree of compression and intraoperative nerve root manipulation. UBE also has a recognized learning curve because of the two-dimensional endoscopic view and the technical demands of instrument coordination (36). Previous studies have shown that UBE operation time for UBE is generally longer than for ACDF (37), indicating room for further refinement of surgical technique and proficiency. Careful positioning is critical, as fluoroscopy-guided Kirschner wire placement can cause spinal cord injury if directed incorrectly.

Overall, both UBE and ACDF achieved comparable pain relief and functional recovery, while UBE demonstrated advantages in motion preservation and earlier return to work. However, several limitations should be acknowledged, including the retrospective design and relatively short follow-up period. Importantly, the consistency of findings between the full and matched cohorts strengthens the validity of our results, suggesting that selection bias was adequately controlled through PSM.

There are several limitations in this study. First, this was a retrospective single-center study and therefore remains subject to selection bias despite the use of PSM and multivariable regression analysis. Second, the follow-up duration was relatively short, which limited our ability to assess long-term cervical stability, delayed deformity, and the durability of motion preservation after UBE. Third, follow-up examinations and imaging assessments were not fully standardized, and some patients lost to follow-up may have sought treatment elsewhere. Finally, there remains a lack of large prospective randomized studies directly comparing UBE and ACDF. Future multicenter prospective studies with clearly defined inclusion criteria, precise characterization of disc morphology, and standardized outcome assessment are needed to determine the optimal surgical strategy for cervical radiculopathy.

Conclusions

In this retrospective cohort study, both UBE and ACDF achieved comparable improvements in pain and functional outcomes in patients with cervical radiculopathy. While no significant differences were observed in VAS or NDI scores between the two groups, UBE was associated with better preservation of cervical ROM and a shorter return-to-work time. In addition, UBE demonstrated a lower overall complication rate compared with ACDF.

However, given the retrospective design and potential for residual confounding, these findings should be interpreted with caution. Further prospective, randomized studies are warranted to validate the long-term efficacy and safety of UBE.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-2026-1-0023/rc

Data Sharing Statement: Available at https://jss.amegroups.com/article/view/10.21037/jss-2026-1-0023/dss

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-2026-1-0023/prf

Funding: This study was supported by the “Epidemiological investigation and related influencing factors and countermeasures of osteoporosis in Hui ethnic settlements in Gansu Province” (No. 24JRZE007).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-2026-1-0023/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. The Institutional Review Board of Norinco General Hospital has approved this retrospective controlled study (No. 202305130818000349884). All participants provided written informed consent. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

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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