Featuring Full-Length Surgical Video Demonstration Below
Endoscopic cervical spine surgery has evolved into a precise, motion-preserving, and minimally invasive option for managing foraminal stenosis and lateral cervical disc herniations. Among available techniques, Biportal Endoscopic Cervical Foraminotomy & Discectomy (UBE) has gained significant traction due to its superior visualization, ergonomic instrumentation, and targeted decompression capability.
This surgeon-focused article highlights the key concepts, indications, technical nuances, and surgical workflow behind UBE cervical decompression — with an operative video included at the end for reference and teaching.
1. Understanding the Role of Cervical Endoscopy in Modern Spine Surgery
Cervical radiculopathy resulting from foraminal stenosis or lateral disc herniations traditionally required open posterior foraminotomy or anterior cervical discectomy and fusion (ACDF). While effective, these approaches involve significant muscle disruption or risk of fusion-related sequelae.
Endoscopic cervical surgery changes this paradigm by offering:
- Minimal tissue disruption
- High-definition visualization
- Motion preservation
- Lower risk of adjacent-segment degeneration
- Fast postoperative recovery
- Potential for day surgery
The UBE technique, in particular, provides the freedom of instrument movement found in microscopic surgery while retaining the magnification and clarity of continuous-irrigation endoscopy.
2. Ideal Indications for UBE Cervical Foraminotomy & Discectomy
Best-suited pathologies
- Foraminal stenosis due to facet hypertrophy or uncovertebral osteophytes
- Lateral or foraminal disc herniations
- Cervical radiculopathy with DRG irritation
- Recurrent radiculopathy after prior ACDF at adjacent levels
- Patients who prefer to avoid fusion surgery
Relative contraindications
- Central canal stenosis with myelopathy requiring anterior decompression
- Severe kyphotic deformity
- Segmental hypermobility
- OLF or severe ossification of PLL
- Very narrow interlaminar window
Proper patient selection remains the cornerstone of successful outcomes.
3. Preoperative Planning: Imaging & Trajectory
UBE requires meticulous planning. Key considerations include:
- MRI for nerve root compression pattern
- CT for bony stenosis and facet morphology
- Evaluation of vertebral artery location (CTA in suspected anomalies)
- Skin-to-facet distance to plan portal entry
- Interlaminar window width for ease of access
Surgeons must visualise the exact corridor needed to reach the lateral recess and foramen without excessive bone removal.
4. Surgical Workflow: Step-by-Step Breakdown
Positioning
- Prone or park-bench position with neutral to slight flexion
- Head support using Mayfield or padded rest
- No routine shoulder traction required
Portal Placement
Two 7-mm incisions:
- Viewing portal: Cranial
- Working portal: Caudal
Both lie just LATERAL to the facet joint line.
Proper triangulation is crucial — it determines the ease of bony work, visibility, and ergonomic instrument mobility.
Key Operative Stages
1. Initial Exposure
- Endoscopic elevation of paraspinal muscles
- Exposure of lamina, V-point, and facet joint
2. V-Point Identification
This is the anatomical gateway formed by:
- Inferior lamina of the cranial vertebra
- Superior lamina of the caudal vertebra
- Medial facet margin
It serves as the target for laminoforaminotomy.
3. Laminoforaminotomy
- Endoscopic drilling of inferior and superior lamina borders
- Targeted medial facetectomy
- Preservation of >50–60% of facet to avoid instability
Continuous irrigation ensures a clear field with excellent visualization of the bony corridor.
4. Exiting Nerve Root Decompression
The exiting root and DRG are identified, exposed, and decompressed by:
- Mobilising epidural fat
- Removing compressive osteophytes
- Widening the foraminal corridor
This step is where endoscopic magnification truly excels.
5. Targeted Discectomy
Under direct endoscopic vision:
- Herniated disc fragments are removed
- No aggressive curettage to preserve disc structure
This maintains stability and avoids unnecessary postoperative disc collapse.
6. Final Inspection
A satisfactory decompression shows:
- Freely mobile nerve root
- Clear pulsatility
- Adequate foraminal diameter
- Hemostasis with bipolar RF
5. Technical Advantages of UBE Over Other Approaches
Compared to Uniportal Endoscopy
- Better instrument freedom
- Less instrument conflict
- More powerful bony decompression capability
- Easier handling of complex foraminal anatomy
Compared to Microscopic Foraminotomy
- Superior visualization around corners
- Continuous irrigation reduces bleeding
- Smaller incisions
- Less muscle disruption
Compared to ACDF
- No implants
- No fusion
- Motion preservation
- Lower adjacent-segment degeneration risk
- Faster return to function
6. Complications — and How to Avoid Them
Common issues:
- Postoperative dysesthesia (DRG irritation)
- Epidural bleeding during early learning curve
- Dural tear (low incidence)
- Excessive facet removal causing instability
- Extremely rare vertebral artery injury
Meticulous technique and restrained bone work mitigate most complications.
7. Evidence and Outcomes
Current literature consistently demonstrates:
- Significant reduction in radicular pain
- Comparable outcomes to ACDF for lateral pathology
- Less postoperative opioid requirement
- Shorter hospital stay
- Excellent patient satisfaction
- Stable long-term results with preserved cervical motion
8. Conclusion
Biportal Endoscopic Cervical Foraminotomy and Discectomy represents a modern, precise, and minimally invasive approach that combines the strengths of endoscopic visualization with the freedom of instrument handling. For lateral and foraminal pathology, it is rapidly establishing itself as a reliable, motion-preserving alternative to ACDF, with excellent outcomes and reduced morbidity.
The surgical video below provides a real-time demonstration of the technique, highlighting anatomical landmarks, operative steps, and the finesse required for safe and effective decompression.
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