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.

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.