title: Thoracic pedicle screws: comparison of start points and trajectories.
abstract: METHODS
  Experimental design using cadaveric computerized tomography (CT) scans and a computer-assisted image guidance system to compare various thoracic pedicle screw start points and trajectories.
  
  
  OBJECTIVE
  To compare described thoracic pedicle screw start points and trajectories to determine which allows strictly intrapedicular screw placement with the most margin of error.
  
  
  BACKGROUND
  Thoracic pedicle screws are being used in a variety of spinal conditions to include fracture, tumor, and deformity. Optimal thoracic pedicle screw start points have received increasing attention in the literature. Optimal thoracic pedicle trajectory is still undetermined.
  
  
  METHODS
  Using fine cut CT scans of 3 cadaveric male specimens (aged 65-70 years) loaded onto a computer-assisted image guidance system, 966 pedicle screws, were virtually inserted. The effective pedicle diameter (EPD) and maximum insertional arc (MIA) was assessed using 3 different trajectories and start points: (1) straight ahead, (2) straight forward, and (3) anatomic. EPD was measured by placing a maximum-sized virtual screw, using a specific trajectory, without cortical violation of the pedicle and/or the vertebral body. The MIA was assessed by measurement of the angle formed by the most superiorly and inferiorly directed 0.1-mm virtual screw through a given start point without violation of the pedicle cortex and obtaining at least 50% vertebral body purchase.
  
  
  RESULTS
  Mean EPD in the sagittal plane was 7.6 +/- 0.3 (SEM) mm for the straight forward trajectory and 9.1 +/- 0.3 (SEM) mm for the anatomic trajectory, a 20% increase (P < 0.0005). Mean EPD in the axial plane was 4.1 +/- 0.2 (SEM) mm for the straight ahead trajectory and 5.0 +/- 0.2 (SEM) mm for the anatomic trajectory, a 22% increase (P < 0.0005). EPD was found to be statistically different based on the trajectory used for placement in both the axial and sagittal planes in the upper (T1-T4), middle (T5-T8), and lower (T9-T12) thoracic spine. Mean MIA in the sagittal plane was 18.7 +/- 1.1 (SEM) for straight ahead start points, 25.8 degrees +/- 0.8 degrees (SEM) for straight forward start points, and 30.2 degrees +/- 0.8 degrees (SEM) for anatomic start points, a 38% increase (P < 0.0005) in MIA compared with straight ahead and a 17% increase (P < 0.0005) in MIA compared with straight forward. Mean MIA in the axial plane was 17.8 degrees +/- 0.6 degrees (SEM) for straight ahead and anatomic start points, and 18.6 degrees +/- 0.6 degrees (SEM) for straight forward start points. This difference was not statistically significant (P = 0.086). MIA was found to be statistically different based on start points used in the sagittal, but not the axial plane, in the upper, middle, and lower thoracic spine.
  
  
  CONCLUSIONS
  EPD and MIA are trajectory (EPD) and start point (MIA) dependent. In the axial plane, anatomic EPD was greater than straight ahead EPD. In the sagittal plane, anatomic EPD was greater than straight forward EPD. Using anatomic start points in the sagittal plane, a greater MIA is achievable. These data suggest that in the diminutive thoracic pedicle or when a larger screw is needed, an anatomic trajectory using anatomic start points may allow a larger bone channel for intrapedicular placement of instrumentation.
authors.affiliation: Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA. aman.dhawan@amedd.army.mil
authors.forename: Aman
authors.initials: A
authors.lastname: Dhawan
authors.forename: William R
authors.initials: WR
authors.lastname: Klemme
authors.forename: David W
authors.initials: DW
authors.lastname: Polly
mesh_terms: D000368:Aged; D001863:Bone Screws; D002102:Cadaver; D006801:Humans; D008297:Male; D019637:Orthopedic Procedures / Q000295:instrumentation / Q000379:methods; D011857:Radiographic Image Interpretation, Computer-Assisted; D015641:Radiography, Interventional; D025321:Surgery, Computer-Assisted / Q000295:instrumentation / Q000379:methods; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D014584:User-Computer Interface