A Comparative Study of the No-Punch Technique in Reducing Surgical Complications Associated with Unilateral Biportal Endoscopic Spine Surgery

<b>Background/Objectives</b>: Unilateral biportal endoscopic spine surgery (UBE) has gained popularity due to its minimal invasiveness, endoscopic magnification, bloodless visual field, and broad application to various spinal disorders. We proposed the "no-punch" technique for UBE spine surgery, emphasizing its capability to prevent neural injury and preserve facet joints. This study aims to examine its efficacy in reducing the risk of incidental durotomy through a comparative study. <b>Methods</b>: A total of 914 consecutive patients with various degenerative spine disorders who underwent UBE surgery between October 2018 and July 2023 by a single surgeon in a single institute were included. The Punch Group consisted of 660 patients (830 segments) who underwent UBE surgeries using Kerrison punches. The No-Punch Group included 254 patients (330 segments) who underwent UBE surgeries without using Kerrison punches. We retrospectively reviewed the medical records and operative videos to identify surgical complications, their management, and final treatment outcomes. <b>Results</b>: Sixty-three surgical complications (58 in the Punch Group), including incidental dural tears, nerve root injuries, incomplete decompression, epidural hematoma, and broken instruments, were identified. The No-Punch Group exhibited a significantly lower overall complication rate (8.8% vs. 2.0%), along with a reduced incidence of dural tears (3.9% vs. 0) and neural injuries (5.3% vs. 0.4%). The improvement was particularly notable in lumbar decompression surgeries (5.0% vs. 0.8%) and revision surgeries (9.9% vs. 0%). <b>Conclusions</b>: The "no-punch" technique enhances the safety of UBE surgery for degenerative spine disorders by understanding the injury mechanisms and modifying the surgical techniques accordingly.