title: The Superior Articular Process as an External Landmark for Determining the Transverse Plane Angulation of Thoracic Pedicles.
abstract: METHODS
  Computed tomographic (CT) study of thoracic spine pedicles.
  
  
  OBJECTIVE
  To analyze the usefulness of the superior articular process (SAP) as an external landmark for determining the transverse plane angulation of thoracic pedicles.
  
  
  BACKGROUND
  The use of thoracic pedicle screws has become commonplace. Although most authors report them to be safe, their use poses a risk to neurovascular structures. Previous studies have provided useful information regarding thoracic pedicle anatomy, but this information is difficult to apply intra-operatively. To avoid neurovascular injury, it is important to determine the correct transverse plane angulation of screw insertion.
  
  
  METHODS
  Two separate investigators reviewed thoracic spine CT scans of 53 patients, 26 years of age or younger. Measurements were taken of the angular relationship of the pedicle and the SAP of T4-T11. A 90° angle was subtended from a line parallel to the SAP with a starting point at the midpoint of the lateral half of the SAP. Measurements were then adjusted laterally for medial breeches and medially for lateral breeches, to align the trajectory down the middle of the pedicle. The degree of correction was recorded. Each investigator made 3 sets of measurements. We calculated kappa values to assess intra-observer/interobserver agreement.
  
  
  RESULTS
  Of the 4,008 measurements, 95.2% were contained within bone, leaving 4.8% pedicle violations. The average correction made for medial and lateral breeches was 6.3% and 6.7%, respectively. The first rater had 92.6% agreement, and an intra-observer kappa value of 0.57. The second rater had a 95.3% agreement and an intra-observer kappa value of 0.40.
  
  
  CONCLUSIONS
  The results support the hypothesis that the SAP can be a useful external landmark for determining the transverse plane angulation of thoracic pedicle screw insertion.
authors.affiliation: Department of Orthopaedic Surgery, University of Missouri-Columbia School of Medicine, One Hospital Dr., Columbia, MO 65212, USA.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Pade
authors.affiliation: Department of Orthopaedic Surgery, University of Missouri-Columbia School of Medicine, One Hospital Dr., Columbia, MO 65212, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Long
authors.affiliation: Division of Orthopaedic Surgery, Children's Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA. Electronic address: jtanderson@cmh.edu.
authors.forename: John T
authors.initials: JT
authors.lastname: Anderson
authors.affiliation: Department of Orthopaedic Surgery, University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO 65212, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Hoernschemeyer
authors.affiliation: Department of Orthopaedic Surgery, Baylor College of Medicine, 6620 Main St., Suite 1325, Houston, TX 77030, USA.
authors.forename: Darrell
authors.initials: D
authors.lastname: Hanson
keywords: Computed tomography; Superior articular process; Thoracic pedicle screws; Thoracic pedicles; Transverse plane angulation