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Funding and support: By JACEP Open policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

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Far lateral disk herniations account for a minority of lumbar disk herniations but may result in weakness and severe radicular pain because the herniated disk compresses the exiting nerve root and dorsal root ganglion (DRG). Traditional approaches for diskectomy that require facet joint violation and/or significant muscle dissection (eg, hemilaminectomy with partial facetectomy or Wiltse approach) have been improved through minimal invasive (MIS) approaches including diskectomy through a tubular or percutaneous endoscopic approach. 1,2 Tubular far lateral microdiskectomy is technically challenging because of a long and narrow surgical corridor that limits visualization and manipulation of surgical instruments. MIS approaches require fluoroscopy to localize the foramen, resulting in prolonged operative time and increased radiation exposure for the patient and surgical team. [3][4][5] To reduce radiation exposure and improve surgical workflow, we demonstrate the first use of a fluoroscopy-based instrument tracking system for incisional planning and foraminal localization before endoscopic transforaminal diskectomy. The system demonstrated uses optical markers calibrated to initial anteroposterior and lateral x-rays taken by a C-arm machine. The markers then attach to surgical instruments for live instrument tracking, which reduces the need for repeat fluoroscopy. Our total fluoroscopy time was 1.2 minutes. The patient is a 75-year-old male who presented with a right L4 radiculopathy from L4-5 far lateral disk herniation. The patient consented to this procedure; participants and any identifiable individuals consented to publication of their image. Five months postoperatively, the patient reported a subjective improvement in pain, with a 4-point decrease in his pain VAS score, from 8 to 4.

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