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Purpose: We describe a technique using orthoganol imaging on a radiolucent table that allows reliable, safe and reproducible insertion of thoracic pedicle screws.

Method: The popularity of pedicle screws for spinal fixation in deformity surgery has increased. Studies have shown lumbar pedicle screws to be safe and effective. The biomechanical superiority of pedicle screws has also been demonstrated. Nonetheless, reluctance to apply the technique to thoracic vertebra remains, most likely because of perceived technical difficulties and a reported high complication rate.

We describe a technique using orthoganol imaging on a radiolucent table, used in a series of patients in whom we have inserted a total of over 2000 screws.

Results: We have inserted over 2000 thoracic pedicle screws without neurological injury. In addition, this technique has allowed us to use pedicle screw to the exclusion of other, less mechanically favourable, methods of fixation to the spine; over the same time period we used only three sublaminar hooks.

Furthermore, the lateral to medial or ‘toeing in’ of screw placement gives greater pull out strength to each screw by increasing the ‘volume’ of bone that has to be overcome before failure by pull out occurs. In addition this trangulation technique allows insertion of :screws of greater diameter than the pedicle and decreases the chance of broaching medially.

Conclusion: Using the technique described, we achieve accurate screw placement ‘first time, every time’, giving us a biomechanically superior construct, allowing more powerful derotation of the spine and thus greater correction of deformity. We recommend its use for all thoracic pedicle screws.

Correspondence should be addressed to: Sue Woodward, Secreteriat, Britspine, Vale Clinic, Hensol Park, Vale of Glamorgan, CF72 8JY Wales.