Comparison of Open Microscopic and Biportal Endoscopic Approaches in Multi-Level Posterior Cervical Foraminotomy: Radiological and Clinical Outcomes

<b>Background/Objectives:</b> This study compares clinical and radiological outcomes of open microscopic posterior cervical foraminotomy (PCF) and biportal endoscopic spine surgery (BESS) PCF in multi-level cases. While BESS PCF is effective in single-level surgeries, its role in multi-level procedures remains unclear. <b>Methods</b>: This retrospective cohort study included 60 patients treated for cervical radiculopathy from 2016 to 2023, divided into two groups, open microscopic PCF (Group M, <i>n</i> = 30) and BESS PCF (Group B, <i>n</i> = 30). Clinical outcomes were assessed using visual analogue scale (VAS) scores for neck and arm pain and the neck disability index (NDI). Radiological parameters included cervical angle, segmental angle, range of motion (ROM), and the extent of facetectomy. <b>Results</b>: Both groups showed improvement in the arm pain VAS and the NDI. However, Group B exhibited significantly better neck pain on the VAS at the final follow-up (<i>p</i> = 0.03). Radiologically, Group B maintained lordotic cervical and segmental angles postoperatively, while Group M showed kyphotic changes (<i>p</i> < 0.01). Segmental ROM was larger in Group M, indicating greater instability (<i>p</i> < 0.01). Group B had less extensive facetectomy while achieving comparable foraminal enlargement. Operative time was longer for Group B (<i>p</i> < 0.001). <b>Conclusions</b>: BESS PCF preserves cervical stability and reduces postoperative neck pain compared to open microscopic PCF in multi-level procedures. Despite longer operative times, its benefits in minimizing instability make it a promising option for treating multi-level cervical radiculopathy. Further research with long-term follow-up is recommended.