title: Maximal access surgery for posterior lumbar interbody fusion with divergent, cortical bone trajectory pedicle screws: a good option to minimize spine access and maximize the field for nerve decompression.
abstract: BACKGROUND
  First advocated by Santoni et al. in 2009, the cortical bone trajectory pedicle screw technique is an alternative to the traditional, convergent technique that shows comparable biomechanical features and potentially requires less aggressive tissue retraction. Aim of this therapy note is to describe this new technique focusing on main advantages and limitations.
  
  
  METHODS
  The authors provide a detailed description of the surgically relevant anatomy focusing on the positioning of the cortical trajectory screws. The surgical technique is then described in a precise step-by-step manner, stressing complication avoidance.
  
  
  RESULTS
  The maximal access surgery posterior lumbar interbody fusion approach is a safe, reproducible procedure allowing for a traditional lumbar spine approach with the benefits of minimal facet joint manipulation and potentially preserving part of their neural innervation and a large part of the paraspinous musculature.
  
  
  CONCLUSIONS
  A dedicated self-retaining retractor and directional neuromonitoring may guide surgeons during the procedure. Nevertheless, the surgeon's knowledge of anatomical landmarks, response to visual and tactile cues and intraoperative decision-making skills remain of paramount importance.
authors.affiliation: Service of Neurosurgery, Department of Clinical Neurosciences, Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland.
authors.forename: Oliver P
authors.initials: OP
authors.lastname: Gautschi
authors.affiliation: Division of Neurosurgery, Department of Neurosciences and Mental Health, University of Turin, Turin, Italy.
authors.forename: Diego
authors.initials: D
authors.lastname: Garbossa
authors.affiliation: Service of Neurosurgery, Department of Clinical Neurosciences, Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland.
authors.forename: Enrico
authors.initials: E
authors.lastname: Tessitore
authors.affiliation: Division of Orthopedics, Faculty of Medicine and Surgery, Second University of Naples, Naples, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Langella
authors.affiliation: Division of Neurosurgery, Department of Neurosciences and Mental Health, University of Turin, Turin, Italy.
authors.forename: Michele F
authors.initials: MF
authors.lastname: Pecoraro
authors.affiliation: Division of Neurosurgery, Department of Neurosciences and Mental Health, University of Turin, Turin, Italy - nicola.marengo@gmail.com.
authors.forename: Nicola
authors.initials: N
authors.lastname: Marengo
authors.affiliation: Division of Neurosurgery, Department of Neurosciences and Mental Health, University of Turin, Turin, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Bozzaro
authors.affiliation: Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
authors.forename: Joshua
authors.initials: J
authors.lastname: Beckman
authors.affiliation: IV Spine Surgery Division, Galeazzi Orthopedic Institute for Scientific Research, Milan, Italy.
authors.forename: Pedro
authors.initials: P
authors.lastname: Berjano
mesh_terms: D019299:Decompression, Surgical / Q000379:methods* / Q000592:standards; D006801:Humans; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D019060:Minimally Invasive Surgical Procedures / Q000379:methods* / Q000592:standards; D065289:Pedicle Screws; D013123:Spinal Fusion / Q000379:methods* / Q000592:standards