Introduction
Cervical spondylotic radiculopathy (CSR) is a common disorder of the cervical spine associated with significant functional impairment [1,2]. The condition is primarily caused by mechanical compression of the cervical nerve roots, most frequently due to intervertebral disc herniation, osteophytes arising from the intervertebral disc, facet joint degeneration, or a combination of these factors. The resultant compression may manifest as neck and shoulder pain, sensory disturbances, including numbness or radicular pain along the affected dermatome, and occasionally as motor weakness. Surgical treatment of CSR offers favorable outcomes; various surgical techniques using anterior or posterior approaches have been described for CSR, each with distinct advantages and disadvantages [3–7].
For decades, conventional anterior approaches have been extensively studied, with anterior cervical discectomy and fusion (ACDF) and cervical disc replacement (CDR) considered as standard surgical options [3,8]. While ACDF provides reliable decompression, it inevitably results in fusion, reducing the range of motion (ROM) and predisposing patients to adjacent segment disease [9]. CDR offers a motion-preserving alternative; however, prosthesis degeneration over time remains a substantial concern, which may ultimately lead to secondary fusion [10]. Posterior cervical foraminotomy (PCF), with or without discectomy, represents another motion-preserving option. Since its first description in 1944, PCF has consistently shown favorable outcomes, and several studies have reported clinical results comparable to anterior techniques [11,12]. Nevertheless, disruption of the posterior tension band (PTB), including ligaments and paraspinal muscles, in PCF is associated with postoperative instability and a relatively high incidence of persistent axial neck pain, highlighting a significant drawback of this technique [5,8].
Recently, minimally invasive spine surgery (MISS) has emerged as an effective alternative to address these limitations; it is aimed at preserving the anatomical structures, promoting faster recovery, and reducing long-term complications. Among these, biportal endoscopic spine surgery (BESS) has been widely adopted for degenerative spinal disorders [13,14]. BESS employs separate working and viewing portals providing a magnified surgical field and greater instrument maneuverability, and allowing precise decompression while minimizing surrounding tissue injury. Building on the favorable results achieved in the lumbar spine, the fundamental principles of BESS have been increasingly refined and extended to more technically demanding regions, including the thoracic and cervical spines [13,15].
Early investigations using biportal endoscopic-PCF (BE-PCF) have demonstrated favorable clinical outcomes, particularly in terms of symptomatic improvement, such as pain reduction and functional recovery, with relatively low complication rates [15–17]. However, most of these studies have been limited by short follow-up durations or a lack of comprehensively evaluated radiological parameters, such as facet joint preservation, global and segmental cervical ROM, and postoperative cervical spine stability. Consequently, the robustness of these outcomes and radiological parameters remains undefined. Therefore, the present study aims to evaluate the clinical and radiological outcomes of BE-PCF at the 1-year follow-up to elucidate its efficacy and safety.
Materials and Methods
In this single-arm retrospective cohort study, we included patients who underwent BE-PCF for CSR between June 2023 and December 2024. The study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Ethics Committee and Institutional Review Board of Xuyen A General Hospital Medical Research Council (approval number: NCKH-27/2025/QD-BVXA). Written informed consent was obtained from all individual participants included in the study.
Inclusion and exclusion criteria
Patients were included if they had: (1) a confirmed diagnosis of CSR at one or two levels and presented with persistent upper extremity radicular pain, with or without motor weakness; (2) magnetic resonance imaging evidence of cervical foraminal stenosis caused by factors such as disc herniation, intervertebral disc osteophytes, or facet joint hypertrophy, consistent with clinical symptoms; and (3) failure of at least 6 weeks of conservative treatment. Exclusion criteria were (1) segmental instability demonstrated on flexion–extension radiographs; (2) cervical canal stenosis causing cervical spondylotic myelopathy; or (3) other concomitant conditions, such as infection, trauma, or tumors.
Surgical procedure
Anesthesia and patient position
The patient was placed under general endotracheal anesthesia in the prone position on a Wilson frame (Fig. 1A). A radiolucent spine table was used, and the table height was adjusted to facilitate fluoroscopic imaging in both anteroposterior (AP) and lateral views. The patient’s head was securely fixed in a neutral position using adhesive tape, while both shoulders were firmly held and maximally pulled caudally to allow clear visualization of the lower cervical vertebrae on lateral fluoroscopy (Fig. 1B, C). The surgeon stood on the symptomatic side of the patient.
Skin incisions and working space
First, the surgical level was confirmed using fluoroscopic images in both AP and lateral views to identify the target point, which in this case was the cranial lamina; this allowed the dilators to rest safely on bony structures while creating the working space. In the AP view, an approximately 1.5-cm long transverse skin incision was made at the level of the inferior border of the caudal pedicle for the working portal (Fig. 2A). After adequate fascial opening, serial dilators were advanced through this incision to detach the paraspinal muscles and reach the cranial lamina. Larger dilators inserted toward the cranial lamina were gradually directed laterally from the midline, ensuring constant bony contact to maintain safety (Fig. 2B).
Next, the skin incision for the scope portal was made approximately 3 cm cranial to the working portal incision when approaching from the left side. Smaller dilators were used to establish triangulation, with the distal contact point positioned near the inferior margin of the cranial lamina. Once true triangulation was achieved and the optimal working corridor was confirmed, the surgical level was established on the lateral fluoroscopic view (Fig. 2C).
Foraminotomy and decompression
We employed a standard BE instrument set with a 0° scope, supplemented by a fine 0.8-mm RF probe and a 1.5-mm curved curette (Fig. 1D). A saline bag was positioned approximately 30 cm above the patient’s neck to secure a stable inflow and outflow system and ensure continuous irrigation. From the cranial lamina, a bipolar RF probe (Arthrocare, Austin, TX, USA) was used to gently clear soft tissues and expose the V-point, defined as the junction of the superior and inferior laminae and the medial facet joint (Fig. 3A1, 3B1). At the same time, the interlaminar space and caudal lamina were also identified.
Before initiating bony decompression, fluoroscopic confirmation was routinely performed in both AP and lateral views to verify the surgical level and the position of the V-point. This step was essential, as even small shifts of the instruments within the narrow cervical interlaminar space could result in the wrong spinal level. A high-speed 3-mm diamond burr (NKS Primado2; Nakanishi Inc., Kanuma, Japan) was then used to drill from the V-point, extending cranially and caudally along the lamina, to gradually enlarge the foramen (Fig. 3A2, 3B2). The burr diameter served as a guide for the extent of bone removal; the medial limit of the foraminotomy was determined when the lateral edge of the ligamentum flavum was exposed. As the bony foramen was progressively thinned, the contour of the exiting nerve root became visible. Final decompression was achieved along the nerve root trajectory, and the residual thin bony was removed with a 1.5-mm curved curette.
Because the cervical nerve root is usually enveloped by a venous plexus, meticulous hemostasis was achieved using the RF probe at the lowest possible energy setting to maintain a clear operative field. In selected cases, partial pediculotomy was performed with a high-speed 2-mm diamond burr to achieve sufficient decompression. This maneuver required the biportal two-handed technique, in which a beveled trocar was placed outside the endoscope to provide dynamic retraction and shielding of the neural elements (Fig. 3A3, 3B3). Adequate decompression was confirmed when the nerve root was freely mobilized, and dural pulsation was clear (Fig. 3A4, 3B4).
Wound closure and postoperative management
Meticulous hemostasis was achieved using the RF probe and Floseal before performing layered wound closure. Postoperatively, patients were placed in a 20° head-elevated position and fitted with a soft cervical collar. Drainage tubes were removed, and early mobilization was encouraged on the first postoperative day. In addition to wound and drain monitoring, patients were put under carefully observation to detect signs of increased intracranial pressure, with particular attention to patients presenting with postoperative hypertension that was difficult to control.
Outcome measures
Clinical outcomes were evaluated using the Visual Analog Scale (VAS) for neck pain and radicular pain, as well as the Neck Disability Index (NDI) for functional assessment. These scores were collected preoperatively, at discharge, at the 6-month follow-up, and at the final (1-year) follow-up.
Radiological outcomes were assessed by comparing flexion–extension radiographs and cervical spine computed tomography (CT) scans obtained preoperatively and 6 months postoperatively. On radiographs, the global C2–C7 ROM and segmental ROM were measured. On CT scans, the following parameters were evaluated: facet length (FL), mid-foraminal diameter (MFD), distal-foraminal diameter (DFD), and foraminal approach angle (FAA). All measurements were performed by independent evaluators who were blinded to the study design to minimize bias.
Statistical analysis
All analyses were performed using STATA ver. 17.0 (Stata Corp., College Station, TX, USA). Continuous variables were expressed as mean±standard deviation, whereas categorical variables were reported as frequencies and percentages. Given the modest sample size, the normality of continuous variables was assessed using the Shapiro-Wilk test. Accordingly, preoperative and postoperative clinical outcomes (VAS for neck pain, VAS for radiating arm pain, and NDI) were compared using paired-sample t-tests or Wilcoxon signed-rank tests based on the normality of data distribution. Subgroup comparisons of categorical variables, such as left-sided versus right-sided approaches, were conducted using chi-square tests. A p-value of <0.05 was considered statistically significant.
To assess whether the study was sufficiently powered to detect clinically meaningful changes, a post hoc power analysis was performed based on the observed effect sizes of the primary clinical outcomes. Cohen’s d values were calculated for paired differences in VAS and NDI to quantify the magnitude of treatment effects.
Results
Patient demographics
A total of 21 patients with CSR with 31 affected levels (mean age: 55.4±12.4 years; range, 37–80 years; males: n=11/21 [52.4%]) were treated with BE-PCF during the study period. The average follow-up duration was 14.8±6.7 months (range, 7–25 months). The mean body mass index of the cohort was 23.7±1.6 kg/m2 (range, 20.6–26.7 kg/m2). Comorbidities, such as diabetes mellitus, hypertension, chronic obstructive pulmonary disease, congestive heart failure, and previous cerebral infarction, were present in 66.7% of cases, whereas osteoporosis was identified in 38.1%. Regarding preoperative symptoms, 71.4% of patients reported sensory disturbances alone, whereas 28.6% presented with both sensory and motor deficits (Table 1).
Perioperative findings
The primary indications for BE-PCF were foraminal stenosis with osteophytes at 13 affected levels (42.0%), cervical disc herniation at nine levels (29.0%), and combined osteophytes with disc herniation in the other nine cases (29.0%). The most frequently operated level was C5–C6 (58.1%), followed by C4–C5 (19.4%), C6–C7 (12.9%), and C3–C4 (9.6%). In terms of the affected side, 16 cases (51.6%) were operated on the left side and 15 (48.4%) on the right side. Regarding surgical extent, 11 patients (52.4%) underwent single-level decompression, whereas 10 patients (47.6%) had two-level procedures. The mean operative time per level was 79.8±27.5 minutes (range, 45–120 minutes), with an average intraoperative blood loss of 140.5±48.1 mL (range, 100–250 mL). The mean length of hospital stay was 5.2±1.8 days (range, 3–10 days). Perioperative complications were minimal, with one case (3.2%) of wrong-level exposure recorded; one patient (4.7%) experienced a transient neurological deficit, while there were no cases of dural tear or infection (Table 2).
Clinical outcomes
All pre- and postoperative VAS and NDI scores were normally distributed (p>0.05), supporting the use of paired t-tests for all pre- and postoperative comparisons. Patients showed significant improvements in both pain and functional scores following BE-PCF (Table 3); the mean VAS scores for neck pain decreased from 6.9±1.1 preoperatively to 3.1±0.7 at discharge, 2.6±0.6 at 6 months, and 2.5±0.7 at the last follow-up (p<0.001). Similarly, mean VAS scores for radiating arm pain improved from 8.1±0.7 preoperatively to 2.6±1.1 at discharge, 2.3±0.7 at 6 months, and 2.0±0.6 at the final follow-up (p<0.001). The NDI scores also decreased from 30.8±3.6 preoperatively to 15.5±2.0 at discharge, 12.8±3.7 at 6 months, and 12.2±1.6 at the last follow-up (p<0.001).
In the post hoc power analysis, the paired differences demonstrated very large effect sizes for all three outcomes (Cohen’s d: VAS for radiating arm pain=5.65, VAS for neck pain=3.92; NDI=5.48). Using these effect sizes with the available sample size (n=21) and α=0.05, the estimated statistical power was computed as 1.000 for all outcome measures, confirming the power of the analysis despite the modest cohort size.
Radiological outcomes
Radiographic assessment showed that the global cervical ROM remained unchanged in the entire cohort (40.5°±10.1° preoperatively vs. 40.5°±10.3° postoperatively, p=0.99). Likewise, segmental ROM also showed no significant difference between pre- and postoperative values (13.1°±4.4° vs. 13.8°±5.7°, p=0.18). CT imaging demonstrated significant bony changes; FL decreased from 13.5±1.6 preoperatively to 8.7±1.3 mm postoperatively (p<0.001). The mean facet resection rate was 34.6%±7.7%, and importantly, no cases exceeded 50% facet removal. The foraminal dimensions were significantly expanded, with the MFD increasing from 4.2±0.8 to 6.5±1.0 mm (p<0.001) and the DFD increasing from 3.7±1.1 to 4.8±1.0 mm (p<0.001) (Table 4).
When radiologic changes were compared between sides, there were no statistically significant differences. The mean facet resection rate was 35.9%±6.4% on the left side and 33.3%±8.9% on the right (p=0.35). The MFD expansion rate was 60.4%±34.1% overall (57.1%±41.9% on the left vs. 63.9%±23.9% on the right side, p=0.58), whereas the DFD expansion rate was 34.7%±27.5% overall (38.3%±31.1% on the left vs. 30.8%±23.5% on the right side, p=0.46). The mean FAA was 9.5°±2.5° overall, with no significant side-to-side difference (8.8°±2.0° on the left vs. 10.2°±2.9° on the right, p=0.13) (Table 5).
Discussion
CSR is a common degenerative disorder that presents with neck pain, radicular numbness, and, in some cases, motor deficits [1,2,7]. Although many patients respond to conservative treatment, surgery remains the preferred approach for those with persistent symptoms or neurological impairment [5–7]. The existing techniques, ACDF, CDR, and PCF, have demonstrated comparable clinical efficacy for treating CSR [3,8,18], yet each carries specific limitations. ACDF results in fusion and may lead to adjacent segment disease [9]. CDR can lead to the development of heterotopic ossification in the long term [10], and PCF may cause postoperative instability and persistent axial neck pain due to disruption of the PTB [11,19,20]. The increasing use of MISS has helped achieve favorable clinical results while addressing the limitations of these conventional procedures [18,21]. BESS was originally introduced for the lumbar spine to offer enhanced visualization, flexible instrument maneuverability, and a true two-handed working environment [13,14]. Based on the encouraging results with BESS reported across various degenerative spinal conditions, this approach was gradually extended to thoracic and cervical pathologies [13].
Early reports documented the clinical effectiveness of BE-PCF for managing CSR [13,14]. As clinical experience with BE-PCF has grown, there is strong evidence corroborating its effectiveness and safety [16,17,21,22], with studies reporting favorable outcomes, low complication rates, and preservation of motion. Heo et al. [16] introduced the “sliding technique” for two adjacent levels, enabling multilevel decompression without the need for additional skin incisions or repeated creation of working portals. A meta-analysis by Lee et al. [17] confirmed that BE-PCF provides outcomes comparable to full-endoscopic PCF, further supporting its safety profile with a reported complication rate of only 6%–8%. Further, Kim et al. [21] demonstrated that uniportal, biportal, and microscopic PCF achieve equivalent midterm clinical results, with endoscopic approaches offering the added advantage of superior facet joint preservation.
Our findings are consistent with previous reports, demonstrating that BE-PCF is effective for both single- and two-level lesions, and can be safely applied to selected cases requiring bilateral decompression at the same level (Table 2). The relatively short operative time, minimal blood loss, and brief hospital stay make this technique particularly valuable for elderly patients with comorbidities, a population in which CSR is highly prevalent. In addition, BE-PCF was found to be effective across different etiologies of CSR, including disc herniation, osteophytic foraminal narrowing, and facet joint degeneration. Beyond indirect decompression achieved through foraminal enlargement, the biportal two-handed technique with a beveled trocar allows direct removal of offending structures, such as extruded disc fragments or bony overgrowth at the vertebral margin, which are common sources of nerve root compression.
In addition to statistical significance, the clinical relevance of postoperative improvement can be interpreted in the context of the minimal clinically important difference (MCID). Previous studies on cervical spine pathologies have proposed MCID thresholds of approximately 2.6 points for VAS-neck pain, 4.1 points for VAS-arm pain, and 17.3% for the NDI using anchor-based and minimum detectable change approaches [23]. In the present study, the magnitude of improvement observed in VAS and NDI scores exceeded these MCID threshold values, suggesting that the clinical benefits of BE-PCF 1 year after the surgery were not only statistically significant but also likely to be clinically meaningful.
These favorable outcomes were reinforced by the low complication rates with this technique; however, several technical precautions are essential to prevent undesirable events. Only one patient (4.7%) developed transient C5 palsy during the early learning phase, which was likely related to excessive RF use near the nerve root. The deficit fully recovered within 3 months, underscoring the importance of applying RF at the lowest energy setting, intermittently rather than continuously, and with caution around neural structures. Additionally, there was one case of wrong-level surgery (3.2%), which underscores the critical importance of accurate cervical level identification. In this case, the patient was scheduled for left-sided BE-PCF at C4–C5 and C5–C6, but the initial decompression was inadvertently performed at C6–C7. The error was promptly recognized when intraoperative fluoroscopy was repeated before proceeding to the next level, allowing the surgery to continue at the correct levels without further complications. This risk is explained by the small size of the cervical lamina and the narrow interlaminar spaces in the cervical spine, which place the vertebral levels in close proximity and make even minor instrument shifts likely to result in wrong-level surgery. To minimize this risk, we recommend marking the V-point and reconfirming the exact level with both AP and lateral fluoroscopy before bony drilling.
Another important safety consideration in cervical biportal endoscopic surgery is the management of irrigation dynamics, as improper fluid handling may lead to elevated epidural pressure and, in extreme situations, increased intracranial pressure [17,24]. Previous studies have demonstrated that cervical epidural pressure can transiently rise during endoscopic decompression, particularly when outflow is obstructed; however, these elevations, typically ranging from 30–45 mm Hg, are not associated with neurological injury [17]. Thus, maintaining an unobstructed inflow–outflow pathway is critical to ensuring a stable and safe operative environment [24]. Additionally, adequate fascial release and continuous monitoring of visualization quality help prevent pressure buildup within the surgical chamber [13,24]. Based on these principles, we maintained an irrigation pressure of <30 mm Hg throughout the procedure to minimize the risk of epidural hypertension, cervical spinal cord compression, or intracranial hypertension.
Revision surgery rates following conventional PCF may be higher than those after ACDF, although the magnitude of this difference remains inconclusive [12]. However, the 1-year follow-up data in our study confirmed the efficacy and safety of BE-PCF; no revision surgeries were required for recurrent radiculopathy or procedure-related instability during the observation period. Dynamic radiographs further demonstrated preservation of both global cervical and segmental ROM, underscoring the motion-preserving benefits of this procedure. This finding is particularly relevant as conventional PCF has been associated with postoperative ROM reduction, especially in multilevel cases [25,26]. Lee et al. [26] reported that nearly half of patients experienced segmental ROM loss >2°, with higher preoperative flexion angles and advanced disc degeneration predisposing to postoperative ROM loss in conventional PCF and even bony bridge formation, which may contribute to persistent neck pain and impaired quality of life. On the other hand, microscopic PCF has been linked to greater kyphotic changes and a higher risk of instability, whereas the BE-PCF can preserve dynamic motion without evidence of instability [25]. Furthermore, the motion-preserving outcomes with BE have been observed not only in ipsilateral BE-PCF (as demonstrated in our study), but also in contralateral BE-PCIF, as described by Song and Kim [27]. Among the two approaches, the ipsilateral technique appears particularly advantageous, offering a familiar surgical view similar to that of open or microscopic surgery and providing more direct access to foraminal structures. The contralateral approach requires crossing the foramen and may carry additional risks to the dura and spinal cord. Furthermore, the learning curve for BE-PCF is relatively short, with technical competency reported after approximately 20 cases [15].
A fundamental principle underlying PCF is to achieve sufficient foraminal decompression to relieve nerve root compression while preserving as much of the facet joint as possible, since resection of more than 50% of the facet area has been shown to increase the risk of segmental instability [28,29]. So far, only a few studies have evaluated postoperative CT to quantify facet preservation [21,27,29]. In our study, standardized CT performed at 6 months postoperatively demonstrated that no case exceeded 50% facet resection, highlighting the extent of precision achievable with BE-PCF. The magnified endoscopic view allowed targeted decompression around the V-point without the need for excessive bony resection. Moreover, the independent working portal facilitated the creation of an inclining drilling trajectory aligned with the exiting nerve root to ensure adequate distal-foraminal decompression as well as limit unnecessary facet removal (Fig. 4). This inclinatory angle could be achieved through the independent working portal using a diamond burr and curved curettes, progressing from the medial to the lateral direction on the ipsilateral side. Consistent with previous reports [21,27], we found that a larger FAA directed laterally correlated with greater decompression of the distal foramen while still maintaining facet preservation. This highlights a key technical advantage of the BE-PCF approach, where ipsilateral access provides both a familiar surgical orientation and sufficient lateral working space to safely expand the foramen with minimal impact on facet stability. When radiological outcomes were compared between left-sided and right-sided procedures performed with the working portal positioned caudally on the left or cranially on the right for a right-handed surgeon, no significant differences were observed across any measured parameters. This suggests that the efficacy and safety of BE-PCF are not influenced by the surgical side, even when the orientation of the working portal is adjusted according to the surgeon’s handedness (Fig. 5).
In summary, BE-PCF is a safe and effective option for managing CSR, delivering favorable clinical and radiological outcomes at 1-year postoperatively, particularly regarding cervical motion preservation and limited facet resection. Nevertheless, there were several limitations to this study that should be acknowledged. First, this was a retrospective cohort study with a relatively small sample and a 1-year follow-up; hence, our findings may be affected by selection and reporting biases. Second, the study was conducted at a single center, and all procedures were performed by a single spine surgeon, which may limit the generalizability of the findings, particularly regarding the complication rates. Cervical biportal endoscopic procedures are widely considered an advanced step in the MISS learning curve, requiring substantial prior experience with lumbar and thoracic endoscopic techniques to ensure a thorough understanding of irrigation dynamics, visualization, and neural safety [13,15,30]. Therefore, the operative efficiency, complication profile, and accuracy of facet preservation observed in this series may reflect the operating surgeon’s prior experience and may not be directly reproducible during the early learning phase of BE-PCF. Third, the absence of a control group for comparison, particularly with established anterior procedures such as ACDF or CDR, or posterior approaches including microscopic PCF, and endoscopic uniportal techniques, represents a major limitation. Each of these techniques carries its inherent shortcomings, many of which are closely related to long-term sequelae, such as adjacent segment degeneration, postoperative cervical ROM reduction, or symptom recurrence. Because these adverse events often require extended follow-up to be fully assessed, the lack of a comparator cohort prevented us from determining whether the favorable outcomes observed with BE-PCF in this study translate to superior long-term durability relative to other surgical options. Nevertheless, our findings underscore the ability of BE-PCF as a motion-preserving, minimally invasive technique, serving as preliminary evidence for future research. Larger comparative studies with longer follow-up periods, systematic reviews, and meta-analyses are warranted to better delineate the relative benefits and long-term implications of BE-PCF within the broader landscape of CSR. Fourth, although VAS and NDI are widely used practical tools for assessing pain and functional disability, they provide only a limited view of overall patient health status; the absence of broader patient-reported outcome measures, such as the 36-Item Short Form Health Survey or the EuroQol-5 Dimension, restricts our ability to evaluate global quality-of-life improvements following BE-PCF. Future studies should incorporate these multidimensional instruments to comprehensively assess postoperative outcomes.
Conclusions
BE-PCF is a safe and effective minimally invasive option for treating CSR; it provides adequate foraminal decompression and offers significant clinical improvement, while preserving cervical ROM, as observed at the 1-year follow-up. The technique used in this study was feasible for both single- and two-level lesions, including selected bilateral cases, and may be beneficial for elderly patients with comorbidities. Nevertheless, given the retrospective design, limited sample size, and relatively short follow-up duration, further multicenter studies with larger cohorts and longer follow-up are required to confirm these findings regarding the role of BE-PCF in CSR management.
Key Points
Key Point 1: Biportal endoscopic posterior cervical foraminotomy (BE-PCF) provides significant clinical improvement with low complication rates at 1-year postoperatively, confirming the durability of these outcomes.
Key Point 2: Radiological evaluation with dynamic radiographs demonstrated preserved cervical range of motion (both global and segmental) post-operatively.
Key Point 3: Postoperative computed tomography at 6 months confirmed facet preservation (<50% resection), effective mid- and distal-foraminal enlargement, and highlighted the inclinatory decompression angle.
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