Freehand Thoracic Pedicle Screw Placement: Review of Existing Strategies and a Step-by-Step Guide Using Uniform Landmarks for All Levels

Pedicle screw fixation in the thoracic spine presents certain challenges due to the critical regional neurovascular anatomy as well as the narrow pedicular corridor that typically exists. With increased awareness of the dangers of intraoperative radiation, the ability to place pedicle screws with anatomic landmarks alone is paramount. In this study, we reviewed the literature from 1990 to 2015 for studies that included freehand pedicle screw placement in the thoracic spine with special emphasis on entry points and the trajectories of the screws. We excluded studies that used fluoroscopy guidance, navigation techniques, cadaveric and biomechanical articles, case reports, and experimental studies on animals. The search retrieved 40 articles, and after careful selection, seven articles were analyzed. Over 8,000 screws were placed in the different studies. The mean accuracy for placement of the thoracic screws was 93.3%. However, there is little consensus between studies in entry points, sagittal, and axial trajectories of the screws. We complete this review by presenting our step-by-step technique for the placement of freehand pedicle screws in the thoracic spine.