Complications in Minimally Invasive Cervical Spine Surgery – Tubular, Uniportal, and Biportal Endoscopic Surgery (2013–2024)

Study Design. Systematic review and proportional meta-analysis. Objective. To assess and compare overall and specific complication rates across tubular, uniportal, and biportal minimally invasive techniques for cervical spine surgery. Summary of Background Data. The three primary minimally invasive spine surgery (MISS) approaches are tubular retractor-based surgery, uniportal endoscopic spine surgery, and biportal endoscopic spine surgery. Each has distinct benefits: tubular approaches rely on familiar instruments and surgical corridors, uniportal techniques reduce skin incision size and tissue disruption, and biportal methods preserve tissue while providing dual working channels that improve surgical access compared to uniportal approaches. However, the relative complication rates of tubular, uniportal, and biportal techniques remain unclear. Methods. This review was registered in PROSPERO (CRD42024594335). Following PRISMA guidelines, we conducted a systematic review and meta-analysis. PubMed, Medline, Embase, and Cochrane Library were searched (Jan 2013–Mar 2024) for cervical MISS studies. Studies with ≥10 adult patients reporting UESS complication rates were included. Conference abstracts, reviews, meta-analyses, and non-English articles were excluded. Study quality was assessed using the Cochrane Risk of Bias tool and Newcastle-Ottawa Scale. A random-effects model was applied. Results. Twenty-one studies (1299 patients) were included, with average patient ages ranging from 47 to 74.5 years and 64% male. All studies had low bias risk. Follow-up periods ranged from 3 to 33 months. The pooled complication rate for cervical MISS was 5% (95% CI [3%-7%]), with heterogeneity (I²=59%). Subgroup analysis showed complication rates of 4% (95% CI [1%-10%], I²=70%) for tubular, 6% (95% CI [2% -12%], I 2 =46%) for uniportal, and 5% (95% CI [2%-8%], I 2 =39%) for biportal. No statistically significant differences were found ( P =0.85). Nerve injury rates were higher with the uniportal approach (6%, 95% CI [2%-16%], P =0.02). Dural tears (1%, 95% CI [0%-2%], I²=0%) and postoperative hematomas (0%, 95% CI [0%-3%], I²=0%) had low incidence, with no significant differences between approaches ( P =0.61 and P =0.78, respectively). Conclusions. Cervical MISS demonstrates a low overall complication rate, with tubular approaches showing a numerically lower risk, though differences were not statistically significant. Larger comparative studies are needed to provide more definitive results for better clinical application.