Endoscopic images while dissectomy
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I now have a comprehensive set of endoscopic discectomy images from Campbell's Operative Orthopaedics (15th Ed, 2026). Here is a full illustrated overview:
Endoscopic Images During Discectomy
Source: Campbell's Operative Orthopaedics, 15th Ed., 2026 - Chapters 44 & 46
1. Approach Planning - Surface Marking
Figure 44.8A - Surface landmarks drawn using fluoroscopy before a transforaminal endoscopic discectomy. Shows midline (dashed line), the measured distance from midline to the start point, and the projected disc space and pedicle levels. Trajectory is drawn from the contralateral caudal pedicle edge to the ipsilateral cranial pedicle.
2. Intraoperative Setup - Right-Sided Approach Marking
Figure 44.8B - Actual intraoperative photograph showing the trajectory lines drawn on the patient's back (prone position) for a right-sided transforaminal discectomy approach. A red laser dot marks the target start point.
3. Fluoroscopic Guidance - Needle/Probe Positioning
Figure 44.9/44.10B - Lateral fluoroscopic image confirming the probe is positioned within the foramen overlying the vertebral body of the caudal level. This confirms correct level and that the instrument is not inadvertently advancing into the disc space.
4. Key Endoscopic View - Arch of Wagner (Most Important Landmark)
Figure 44.10A - This is the critical endoscopic view through the working cannula during transforaminal discectomy. The labeled structures are:
- SAP (Superior Articular Process) - at the top
- Pedicle - on the left
- Arch of Wagner (red arc) - the bony arch formed between the inferior pedicle and the superior articular process; this is the key orienting landmark in the foramen
- Annulus - visible centrally/inferiorly, representing the posterior disc
Once the Arch of Wagner is confirmed, instruments are directed to remove herniated disc material from under the nerve root.
Figure 44.10B - Corresponding AP fluoroscopic view showing the ball-tip probe lying within the foramen at the correct level.
5. Axial Diagram - Trajectory Angulation
Figure 44.7 - Axial view illustrating how trajectory angulation affects target access:
- The blue tube (more lateral start point) is used for central herniations - flatter trajectory
- The red/brown tube (more medial start point, steeper trajectory) is used for far lateral herniations
- The colored dots in Kambin's triangle represent: gray = safe working zone, red = exiting nerve root, blue = traversing nerve root
- The gray instrument (top) represents an interlaminar approach for comparison
Key Endoscopic Anatomy Checklist During Discectomy
| Structure | What to Look For |
|---|---|
| Arch of Wagner | Bony arch (pedicle + SAP) - primary orienting landmark |
| Annulus fibrosus | Fibrous disc wall; incise to access nucleus |
| Epidural fat | Yellowish tissue around nerve structures |
| Traversing nerve root | Displaced dorsally by herniation; seen pulsating after decompression |
| Exiting nerve root | Identified for foraminal/far lateral herniations |
| Dura | Avoid injury; pulsation confirms decompression |
| Epidural veins | Control with fluid pressure (do not exceed diastolic BP) |
Endpoints for Adequate Decompression (Endoscopic)
The textbook describes decompression as complete when:
- The affected nerve root is seen pulsating to heartbeat without deformity
- The patient (awake under MAC) reports resolution of the typical radicular pain
- The nerve root is freely retractable medially and laterally, and is round
- Campbell's Operative Orthopaedics, 15th Ed., 2026 - Techniques 44.3, 46.5, 46.6
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