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Free Hand Pedicle Screw Placement in the Thoracic Spine without Any Radiographic Guidance : Technical Note, a Cadaveric Study.
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PMID:  22396849     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Thoracic pedicle screw fixation techniques are still controversial for thoracic deformities because of possible complications including neurologic deficit. Methods to aid the surgeon in appropriate screw placement have included the use of intraoperative fluoroscopy and/or radiography as well as image-guided techniques. We describe our technique for free hand pedicle screw placement in the thoracic spine without any radiographic guidance and present the results of pedicle screw placement analyzed by computed tomographic scan in two human cadavers. This free hand technique of thoracic pedicle screw placement performed in a step-wise, consistent, and compulsive manner is an accurate, reliable, and safe method of insertion to treat a variety of spinal disorders, including spinal deformity.
Seung-Jae Hyun; Yongjung J Kim; Gene Cheh; Seung Hwan Yoon; Seung-Chul Rhim
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Publication Detail:
Type:  Journal Article     Date:  2012-01-31
Journal Detail:
Title:  Journal of Korean Neurosurgical Society     Volume:  51     ISSN:  1598-7876     ISO Abbreviation:  J Korean Neurosurg Soc     Publication Date:  2012 Jan 
Date Detail:
Created Date:  2012-03-07     Completed Date:  2012-08-23     Revised Date:  2013-05-29    
Medline Journal Info:
Nlm Unique ID:  101467054     Medline TA:  J Korean Neurosurg Soc     Country:  Korea (South)    
Other Details:
Languages:  eng     Pagination:  66-70     Citation Subset:  -    
Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
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Journal Information
Journal ID (nlm-ta): J Korean Neurosurg Soc
Journal ID (publisher-id): JKNS
ISSN: 2005-3711
ISSN: 1598-7876
Publisher: The Korean Neurosurgical Society
Article Information
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Copyright © 2012 The Korean Neurosurgical Society
Received Day: 27 Month: 7 Year: 2011
Revision Received Day: 20 Month: 9 Year: 2011
Accepted Day: 11 Month: 1 Year: 2012
Print publication date: Month: 1 Year: 2012
Electronic publication date: Day: 31 Month: 1 Year: 2012
Volume: 51 Issue: 1
First Page: 66 Last Page: 70
ID: 3291712
PubMed Id: 22396849
DOI: 10.3340/jkns.2012.51.1.66

Free Hand Pedicle Screw Placement in the Thoracic Spine without Any Radiographic Guidance : Technical Note, a Cadaveric Study
Seung-Jae Hyun, M.D., Ph.D.1
Yongjung J. Kim, M.D.2
Gene Cheh, M.D.3
Seung Hwan Yoon, M.D., Ph.D.4
Seung-Chul Rhim, M.D., Ph.D.5
1Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
2Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
3Department of Orthopedic Surgery, Wooridul Spine Hospital, Seoul, Korea.
4Department of Neurosurgery, College of Medicine, Inha University, Incheon, Korea.
5Department of Orthopaedic Surgery, Spine Service, Columbia University College of Physicians and Surgeons, New York, NY, USA.
Correspondence: Address for reprints: Seung-Chul Rhim, M.D., Ph.D. Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea. Tel: +82-2-3010-3554, Fax: +82-2-476-6738,


Pedicle screw fixation is a necessary part of various spinal surgeries. Despite many advantages of using pedicle screws, their usage in the spine is replete with danger and has the potential for permanent neurologic deficit especially when placing screws near the spinal cord at the concave apex of a scoliotic thoracic spine4,9,10,14). There are several methods of pedicle screw placement that have been developed to enhance the safety of its usage. Some surgeons first identify anatomical landmarks by intraoperative C-arm image intensifier or K-wires placement into the pedicles8,15). It is time consuming to take C-arm images after each pedicle screw placement and to rearrange the drapes each time an image is taken. Others utilize stereotactic image guided systems that are based on preoperative computerized tomographic (CT) scan or fluoroscopy1,5,13). The stereotactic image guided systems requires preoperative CT scan with exposure to high levels of radiation, higher cost, the need for expensive equipment, and prolonged operation time.

Although these techniques slightly increase placement accuracy, they are also associated with increased radiation exposure to the patient and surgeon as well as increased operative time. In the present study, we describe our experience with the placement of pedicle screws in the thoracic spine using a free hand technique without any radiographic guidance. Moreover, we conducted a cadaveric study to evaluate the accuracy and safety of this technique.


Two thoracic spine cadaver specimens were assigned to test the accuracy of this free hand technique for transpedicular screw fixation. The accuracy of transpedicular screws was confirmed using intraoperative C-arm images and naked eye examination. To objectively evaluate the position of the screws inserted, postoperative computed axial tomography (CAT) scans were performed. The relative position of the screw inside the pedicle by the CAT scan was graded as follows : 1) contained : axis of the pedicle screw is between the medial and lateral pedicle walls completely; 2) medial violation : axis of the pedicle screw is out of medial wall of the pedicle; and 3) lateral violation : axis of the pedicle screw is out of the lateral pedicle walls. The positions of the scanned pedicle screws were determined by two senior spine surgeons.

Surgical technique

Free hand pedicle screw placement is performed using anatomic landmarks. The surgical technique of free hand transpedicular screw placement can be broken down into specific steps that are repeated at each level.

Incision and exposure

The first important component of successful thoracic screw placement is meticulous exposure of the posterior elements. The spine is exposed to the tips of the transverse processes bilaterally and to the lateral border of the superior articular process (SAP), staying strictly subperiosteal to reduce bleeding. The facet joints must be thoroughly cleaned of soft tissue (Fig. 1). The inferior facets are removed with a 0.5-inch straight osteotome (down to T10) or rongeur (below T10).

The cortical burring of starting point

The starting point of the T1-T3 and T12 vertebra is at the junction of the bisected transverse process and lamina at the lateral border of the pars. There is a trend towards a more medial and cephalad (proximal) starting point on the posterior elements as one proceeds to the apical midthoracic region (T7-T9) level by level (Fig. 1). The starting point of the apical midthoracic region (T7-T9) is the most medially proximally located, at the junction of the proximal edge of the transverse process and just lateral to the mid portion of the base of the SAP (usually just 2-3 mm medial to the lateral border of the pars). Above the midthoracic region, the starting point tends to move slightly lateral and caudad as one proceeds more proximal in the thoracic region. The starting point of the T4, T5, and T11 is at the junction of the proximal one third of the transverse process and lamina just medial to the lateral border of the pars. Lastly, the starting point of the T6 and T10 is at the junction of the upper laminar ridge and lamina just medial to the lateral border of the pars. It is advantageous to note these trends when placing a screw at each level in succession, working from distal to proximal in the thoracic spine, to make fine adjustments to the trajectory of the next screw base on the previous level screw or contralateral screw. A 3 mm cutting burr is utilized to create posterior cortical breach, approximately 5 mm in depth.

Gearshift probing

The gearshift is initially pointed lateral as a safety measure to avoid medial wall perforation (Fig. 2). Gearshift was advanced from the desired starting point toward the center of the isthmic part. After inserting the gearshift tip approximately 15-20 mm (to beyond the isthmic part of the pedicle), the gearshift is removed and confirmed 5 bony walls through ball-tip. Then, the tip of the gearshift turned to face medial. The pedicle finder is advanced with an ultimate depth averaging 25-40 mm in the thoracic spine. It is important to make sure that surgeon to feel the bone of entire length of the pedicle and body.

Palpation and pedicle length measurement

Once the pedicle seeker is removed, the tract is visualized. A flexible ball-tipped pedicle sounding or palpating device is utilized to palpate five distinct bony borders : a floor and four walls (medial, lateral, superior and inferior). At this point, if a soft tissue breach is palpated, there may be an opportunity to redirect the screw into an appropriate position into the pedicle. If any wall including the medial has been breached, the pedicle may be salvageable. Otherwise, we place bone wax in the pedicle hole to eliminate the bleeding and re-angle the pedicle finder with a more appropriate trajectory.

Tapping, repalpation and screw placement

The pedicle tract is undertapped with a 1 mm less diameter tap than the intended screw. Following this, the pedicle tract is palpated again to make sure that the five osseous borders are intact. This second palpation will often allow palpation of distinct bony ridges confirming intraosseous position and the tract length is remeasured with a hemostat. This measurement is compared directly adjacent to the screw to be placed to ensure appropriate screw length. Next, the screw is placed slowly down the pedicle into the body in the same alignment to confirm it is threaded properly and allow for viscoelastic expansion.

Confirmation of intraosseous screw

It is imperative that the surgeon document intraosseous placement via fluoroscopy and/or radiography. The coronal plane radiograph is evaluated for the harmonious position of all screws especially when any rotational scoliosis deformity exists. In cases of shorter or longer screws compared to adjacent screws, the screw length as viewed on the lateral X-ray is mandatory to check for harmonious position. On the lateral X-ray, the screws should be parallel to the superior endplates, and not extending past the anterior border of the vertebral body. These two plane radiographs should confirm the harmonious position of the screws (Fig. 3, 4).


A total of 48 thoracic pedicle screws were inserted in two cadavers. The diameter of the screws used in the thoracic spine ranged from 4.5 to 7.5 mm. The number of the screws inserted were as follows (total n=48). The levels operated were T1-T6 (24) and T7-T12 (24). All 48 transpedicular screws inserted into the thoracic spine were all evaluated by C-arm, naked eye examination and CAT scan to assess for screw position (Fig. 4). Among 48 pedicle screws inserted, thoracic pedicle screws were accurately placed in 97.9% (47 of 48). Only one screw (2.1%) showed medial cortical perforation which meant the central line of the pedicle screw was out of the medial cortex of the pedicle wall (Fig. 5).


Pedicle screw fixation has the advantage of purchase of all three spinal columns without encroaching into the spinal canal3). This theoretical advantage has been translated to superior clinical results in fracture fixation as well as in deformity correction7,9-11,14,15). However, their usage in the spine has the potential for permanent neurologic deficit, especially when placing screws near the spinal cord at the concave apex of a scoliotic spine2,4,9,12,16). The safety margin for this technique has been improved through the use of image-guided techniques1,5,13). Nevertheless, these newer techniques require additional equipment as well as the use of fluoroscopy which increases the radiation exposure.

Some surgeons identify anatomical landmarks by K-wires placement into the pedicles. The incidence of pedicle screw misplacement ranges from 1.5% to 25% using the K-wire guided methods2,10,15). Although previous research showed only 1.5% misplacement, they admitted that the actual rate would be higher as their patients were primarily evaluated by the postoperative radiographs15). Conventional K-wire guide technique could not allow direct visualization of the starting point on the intraoperative fluoroscopy and/or radiography. In the present study, only one pedicle screw of 48 (2.1%) demonstrated violations (1 medial violation in cadaver), even after the postoperative CT scan evaluation of all pedicle screws enrolled.

Recently, the free hand technique has gained popularity. One of the authors reported a series in which 3400 screws had been placed by the free hand technique without neurovascular complications, and only 6% had moderate breaches6,7). Although their experience demonstrates that pedicle screws can be consistently placed in an accurate fashion using the described free hand method, it is important that each surgeon use whatever assistive device or technique that surgeon may require to accurately place pedicle screws.


The placement of thoracic pedicle screw using the free hand technique without any radiographic guidance appears to be an accurate, reliable, and safe method of insertion without more radiation or time consuming. Nevertheless, before using this technique, surgeon must have a thorough knowledge of vertebral anatomy, follow and use diligent and repetitive confirmatory steps to compulsively assure intraosseous placement.

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2. Brown CA,Lenke LG,Bridwell KH,Geideman WM,Hasan SA,Blanke K. Complications of pediatric thoracolumbar and lumbar pedicle screwsSpine (Phila Pa 1976)Year: 199823156615719682313
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5. Kim KD,Johnson JP,Babbitz JD. Image-guided thoracic pedicle screw placement : a technical study in cadavers and preliminary clinical experienceNeurosurg FocusYear: 200110E216749749
6. Kim YJ,Lenke LG,Bridwell KH,Cho YS,Riew KD. Free hand pedicle screw placement in the thoracic spine : is it safe?Spine (Phila Pa 1976)Year: 200429333342 discussion 342. 14752359
7. Kim YJ,Lenke LG,Cheh G,Riew KD. Evaluation of pedicle screw placement in the deformed spine using intraoperative plain radiographs : a comparison with computerized tomographySpine (Phila Pa 1976)Year: 2005302084208816166900
8. Kuntz C 4th,Maher PC,Levine NB,Kurokawa R. Prospective evaluation of thoracic pedicle screw placement using fluoroscopic imagingJ Spinal Disord TechYear: 20041720621415167336
9. Li G,Lv G,Passias P,Kozanek M,Metkar US,Liu Z,et al. Complications associated with thoracic pedicle screws in spinal deformityEur Spine JYear: 2010191576158420237943
10. Liljenqvist UR,Halm HF,Link TM. Pedicle screw instrumentation of the thoracic spine in idiopathic scoliosisSpine (Phila Pa 1976)Year: 199722223922459346144
11. Liljenqvist UR,Link TM,Halm HF. Morphometric analysis of thoracic and lumbar vertebrae in idiopathic scoliosisSpine (Phila Pa 1976)Year: 2000251247125310806501
12. Lonstein JE,Denis F,Perra JH,Pinto MR,Smith MD,Winter RB. Complications associated with pedicle screwsJ Bone Joint Surg AmYear: 1999811519152810565643
13. Rajasekaran S,Vidyadhara S,Ramesh P,Shetty AP. Randomized clinical study to compare the accuracy of navigated and non-navigated thoracic pedicle screws in deformity correction surgeriesSpine (Phila Pa 1976)Year: 200732E56E6417224800
14. Sarlak AY,Tosun B,Atmaca H,Sarisoy HT,Buluç L. Evaluation of thoracic pedicle screw placement in adolescent idiopathic scoliosisEur Spine JYear: 2009181892189719526376
15. Suk SI,Kim WJ,Lee SM,Kim JH,Chung ER. Thoracic pedicle screw fixation in spinal deformities : are they really safe?Spine (Phila Pa 1976)Year: 2001262049205711547207
16. West JL 3rd,Ogilvie JW,Bradford DS. Complications of the variable screw plate pedicle screw fixationSpine (Phila Pa 1976)Year: 1991165765792053001

Article Categories:
  • Technical Note

Keywords: Pedicle screw placement, Thoracic spine, Surgical anatomy, Free hand technique, Surgical technique, Cadaveric study.

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