Purpose <p>Unilateral biportal endoscopic posterior cervical foraminotomy (UBE-PCF) has emerged as an effective minimally invasive technique for cervical radiculopathy. However, no comparative study has investigated clinical and radiological outcomes between ipsilateral and contralateral inclinatory approaches. This study aimed to analyze and compare outcomes between these two UBE-PCF approaches.</p> Methods <p>Sixty consecutive patients who underwent UBE-PCF for cervical radiculopathy at a single institution were retrospectively reviewed (ipsilateral: 70 levels, contralateral inclinatory: 34 levels). Clinical outcomes included neck and arm visual analog scale (VAS) scores and Neck Disability Index (NDI). Radiological outcomes were assessed using X-ray (C2/C7 Cobb angle, segmental angle, disc height), CT (isthmic distance, superior articular process distance, facet length, facet cross-sectional area, surgical foraminal approach angle) and MRI (interforamianl cross-sectional area). Statistical analyses were performed to compare outcomes and assess correlations between surgical foraminal approach angle and radiological parameters.</p> Results <p>Both approaches achieved significant improvement in neck VAS, arm VAS, and NDI postoperatively, with no statistically significant differences between two groups. Radiological parameters improved significantly in both groups, with no cases of postoperative instability. Although the contralateral inclinatory approach demonstrated slightly smaller surgical foraminal approach angle and lower facet joint resection rates, these differences were not statistically significant. Surgical foraminal approach angle was not significantly correlated with facet resection rates.</p> Conclusion <p>Both ipsilateral and contralateral inclinatory UBE-PCF provide comparable clinical and radiological outcomes. UBE spine surgeons can select either approach based on preference and anatomical considerations, as both approaches effectively decompress cervical nerve root.</p>