Thoracic pedicle screw placement: Free-hand technique

Thoracic pedicle screws provide a number of advantages over other methods of spinal fixation in treating a variety of conditions including: better pull-out strength and greater control in the sagittal, coronal and rotational planes due to increased stability to axial, bending and rotational forces by three-column fixation, fewer vertebral motion segments arthrodesed, no or lessened need for postoperative bracing and secure fixation after laminectomy or incompetent posterior elements. In patients with spinal deformity, segmental pedicle fixation has demonstrated greater three-dimensional correction with decreased rates of curve progression and higher fusion rates, the ability to treat the rigid scoliosis between 70 and 100 curves without anterior release with smaller total hospital cost and direct apical vertebral derotation to enhance correction and potentially obviate the need for a thoracoplasty. Also, the flexibility of multiple screw types allows easier connection to rods, especially in patients with deformity. Despite the potential benefits, many surgeons have avoided placing thoracic pedicle screws because of their concern on neurologic, vascular and visceral complications. 26] The purpose of this manuscript is to delineate the “Free-Hand” thoracic pedicle screw placement with respect to the pertinent anatomy, placement technique, confirmation of the accurate screw placement, salvage, reported complications and several methods to help avoid such complications.