BackgroundMinimally invasive spine surgery is a field of active and intense research. Image-guided percutaneous pedicle screw (PPS) placement is a valid alternative to the standard free-hand technique, thanks to technological advancements that provide potential improvement in accuracy and safety. Herein, we describe the clinical results of a surgical technique exploiting integration of neuronavigation and intraoperative neurophysiological monitoring (IONM) for minimally invasive PPS.Materials and MethodsAn intraoperative-computed tomography (CT)-based neuronavigation system was combined with IONM in a three-step technique for PPS. Clinical and radiological data were collected to evaluate the safety and efficacy of the procedure. The accuracy of PPS placement was classified according to the Gertzbein–Robbins scale.ResultsA total of 230 screws were placed in 49 patients. Only two screws were misplaced (0.8%); nevertheless, no clinical sign of radiculopathy was experienced by these patients. The majority of the screws (221, 96.1%) were classified as grade A according to Gertzbein–Robbins scale, seven screws were classified as grade B, one screw was classified as grade D, and one last screw was classified as grade E.ConclusionsThe proposed three-step, navigated, percutaneous procedure offers a safe and accurate alternative to traditional techniques for lumbar and sacral pedicle screw placement.Level of EvidenceLevel 3.Trial registrationNot applicable.