Beyond Facets, Beyond Dogma: Endoscopically Directly Visualized Medial Branch Transection for the Axial-Radicular Pain Spectrum

PURPOSE: To define directly visualized endoscopic posterior sensory network interruption (endoscopic transection/neurectomy of targeted dorsal ramus tributaries) as surgically distinct from percutaneous fluoroscopy-guided radiofrequency lesioning, and to propose a bounded, physiology-informed pathway that positions it after functional confirmation, and before structural reconstruction in selected phenotypes. STUDY DESIGN: Narrative, mechanism-informed perspective. METHODS: Selective synthesis of peer-reviewed evidence on dorsal root ganglion (DRG) neurobiology, functional diagnostics, imaging-symptom noncorrelation, and endoscopic posterior sensory procedures; and development of an operational decision framework specifying pragmatic diagnostic anchors, exclusion thresholds, reassessment expectations, and stopping rules. RESULTS: Axial and radiating/appendicular symptoms frequently coexist along a continuum influenced by DRG excitability rather than separating cleanly into "facet" vs "compression" categories. In imaging-noncorrelative presentations, magnetic resonance imaging noncorrelation is treated as a diagnostic classification rather than an indication: directly visualized endoscopic neurectomy is considered only when a suspected level/pathway is physiologically localized using predefined functional confirmation (eg, concordant diagnostic testing with clinically meaningful immediate relief) and when competing dominant mechanisms (instability, deformity, or predominant neuromuscular failure) are reasonably excluded. The framework constrains procedural "dose" and retreatment through explicit safety boundaries, including conservative multilevel use, interval objective neuromuscular reassessment, and stopping rules-particularly in patients with multifidus compromise, sarcopenia/frailty phenotypes, extensor-compartment vulnerability, or radiographic instability. CONCLUSIONS: Directly visualized endoscopic interruption of medial branch and related dorsal ramus tributaries is a surgical procedure with verified anatomic access under endoscopic visualization and should be distinguished from needle-based fluoroscopic radiofrequency lesioning when interpreting technique, reach, outcomes, and risk. Within a restricted, auditable selection framework requiring functional confirmation and defined safety boundaries, it may serve as a motion-preserving, escalation-friendly option in selected DRG-dominant axial-radiating pain phenotypes, while preserving escalation pathways to decompression or fusion when structural progression becomes dominant. CLINICAL RELEVANCE: A DRG-centered, endoscopic framework may address a common treatment gap-function-limiting symptoms with noncorrelative routine imaging-by pairing functional diagnostics with directly visualized posterior sensory network interruption while maintaining longitudinal accountability for neuromuscular and biomechanical risk.