With the arrival of an aging society, the number of patients with cervical spondylotic radiculopathy (CSR), which is one of the degenerative spinal diseases, is increasing rapidly (1). CSR is the most common form of cervical spondylosis, mainly due to cervical nerve root compression caused by disc degeneration, herniation, segmental instability, or other conditions, mainly manifested as neuropathic radicular pain. CSR, the most prevalent form of cervical spondylosis, is caused by cervical nerve root compression due to disc degeneration, herniation, segmental instability, or other conditions, mainly manifested as neuropathic radicular pain (2). Although anterior cervical discectomy and fusion (ACDF) is the gold standard surgical strategy for the treatment of CSR, it has several disadvantages, including adjacent segment degeneration, incision and implant-related complications, and high hospitalization costs (3). In addition, it is reported that anterior open surgery is closely associated with a high risk of postoperative dysphagia (4). Consequently, minimally invasive spinal surgeries have emerged with similar clinical outcomes, which have several advantages, including less injury, shorter hospital stay, and fewer postoperative complications (5).

Unilateral biportal endoscopy (UBE) is a minimally invasive spinal surgery with minimal injury to the surrounding structures, thereby greatly increasing the stability of the operated segment (6). Currently, UBE has gradually been applied for cervical disorders with remarkable efficiency and conveniency (6, 7).

However, whether piezosurgery can be used in UBE surgery has not been reported. This study aimed to evaluate the efficacy and safety of UBE foraminotomy and diskectomy combined with piezosurgery for treating CSR with neuropathic radicular pain

Table 1 shows the mean operation time and intraoperative blood loss. Postoperative CT scan revealed adequate enlargement of the cervical canal and nerve root (Figure 3). At the final follow-up, VAS scores of the neck and arm and NDI scores were significantly improved compared to the pre-operation (Figure 4).

No specific complications occurred during surgery and the immediate postoperative period. No patient required additional surgery for sustained or aggravated symptoms during postoperative hospitalization. No patient had the nerve or vascular injury during surgery, and no patient experienced persistent or aggravated symptoms during the postoperative hospitalization.

CSR, mainly manifested as neuropathic radicular pain, is one of the common spinal disorders and usually requires only conservative treatment. However, when conservative treatment fails, surgery is necessary to relieve the symptoms by removing the compression (8). Generally, ACDF is the primary surgical strategy for CSR with good outcomes, however, it is accompanied by several limitations, including limited neck mobility, adjacent segment degeneration, and high reoperation rate (9–11). In addition, there is conflicting evidence regarding the efficacy of anterior foraminotomy, with reported success rates of 52–99%, but recurrence of radicular symptoms is as high as 30% (12).

With the development of new technology and devices, the application of minimally invasive endoscopic surgery to treat CSR is gradually increasing, with better outcomes and fewer complications compared to ACDF (13–15). A decade ago, percutaneous endoscopic cervical diskectomy using a small-sized single portal was introduced, which was reported to not only minimize surgical trauma but also effectively relieve compression (16, 17). However, working and viewing in the same narrow portal manifested several difficulties, such as disorientation and difficulty in maneuvering (18, 19).

Currently, UBE technology represents a relatively recent development in minimally invasive spine surgery (20, 21). Compared with uniportal endoscopic surgery, UBE with two portals has important advantages in improving the scope of the surgical field and the freedom of working devices. Through independent viewing and working portals, the operator can maneuver comfortably with working devices, such as piezosurgery and drills, to expand the range of exploration and decompression. Moreover, independent control of the 30-degree endoscope can enlarge the surgical field of view, which is conducive to the observation of tiny blood vessels and ligaments, thereby reducing iatrogenic blood vessels and neurological injuries. At the same time, the use of continuous irrigation not only provides a clearer view to preventing intraoperative complications but also flushes away inflammatory factors to reduce postoperative pain and the risk of infection (22).

As we all know, the vessels and nerves around the spine are dense and complex. During foraminotomy and diskectomy, there is a risk of unintended injury to the nerve root, blood vessel, and dura. In particular, rotary drills are commonly used to remove bone tissue, however, they undoubtedly increase the risk of neurovascular structures due to their rotational power and limited operating space (23). Piezosurgery technique is based on micro-vibrations, which selectively cuts bone tissue and preserve surrounding soft tissue structures (24). Piezosurgery device performs bone cutting by controlled scraping motion without rotational power, which provides precise and safe bone removal procedures with reduced risk to adjacent soft tissue (25). To our knowledge, the present study first combined Piezosurgery device and UBE for cervical foraminotomy and discectomy to optimize surgical precision and reduce surgical risks. A series of foraminotomy and diskectomy in 12 patients with CSR was performed, which showed that the postoperative VSA and NDI scores were significantly improved at the final follow-up. No nerve or vascular injury occurred during surgery and the immediate postoperative period. Meanwhile, no patient experienced persistent or aggravated symptoms during the postoperative hospitalization.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Ethics Committee of Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine. The patients/participants provided their written informed consent to participate in this study.

Conceptualization: YJ. Methodology: BZ. Validation: MZ. Writing original draft preparation: PZ. Writing-review and editing: XY. Project administration: QZ. All authors contributed to the article and approved the submitted version.