Musculoskelet Surg
DOI 10.1007/s12306-016-0438-8
REVIEW
Pedicle screw insertion techniques: an update and review
of the literature
F. Perna1 • R. Borghi1 • F. Pilla1 • N. Stefanini1 • A. Mazzotti1 • M. Chehrassan1
Received: 10 November 2016 / Accepted: 11 November 2016
Ó Istituto Ortopedico Rizzoli 2016
Abstract Pedicle screw construct have become one of the
most practiced procedure in spinal surgery. Despite com-
monly used, questions remain about their safety especially
for the thoracic spine and in deformity where difficulty in
positioning can lead to pedicle breach and adjacent struc-
tures injury. Misplacement rates have been reported to be
from 5 to 41% in the lumbar spine and from 3 to 55% in the
thoracic spine. Hence, various procedures have been
described in order to improve pedicle screw insertion
accuracy. Aim of this study is to evaluate current concepts
on pedicle screws placement techniques to better under-
stand recent attitude and clarify some doubts when
selecting the most proper method.
Keywords Computer-assisted surgery
Navigation

Spondylolisthesis
Scoliosis
Spinal stenosis

Fluoroscopy
Freehand
Vertebral entry points
Introduction
Solid posterior spinal construction with pedicle screws and
rods has become the most applied instruments for the
majority of spinal surgery procedures [1].
Indications for their use include congenital disease,
deformity such as scoliosis or hyperkyphosis, trauma,
spinal tumors, infection and degenerative disease.
Initially, due to the greater diameter of the pedicles in
the lumbar spine and lesser risk of vital structure damage,
pedicle screws were exclusively used in the lumbar spine
& F. Perna
pernafa@gmail.com
1
Istituto Ortopedico Rizzoli, Bologna, Italy
[2]. Subsequently, considering the excellent results
obtained in the lumbar spine, the use of pedicle screws
was extended to the thoracic spine. However, due to the
presence of more vital structures nearby to thoracic
pedicles, a less margin of error can be admitted in this
area and screws misplacement can easily lead to more
serious damages [3].
The risk of screw malposition can be even increased in
case of spine deformities where vertebral anatomy can vary
widely particularly in mid-thoracic zone where the pedicles
are thinner and the spinal cord is immediately adjacent to
the pedicle’s medial border [4].
The rate of pedicle screws misplacement has been
reported from 5 to 41% in the lumbar spine and from 3 to
55% in the thoracic spine [5–9].
To facilitate the evaluation of pedicle screw misplace-
ment, medial pedicle violation of more than 4 mm poten-
tially is considered at high risk of damage to the neural
structures. Violation up to 4 mm are considered at lower
risk and breach of the pedicle below 2 mm are considered
in the ‘‘safe zone’’ with low risk of neural damage [5].
However, no consensus exists in the literature regarding the
so-called safe zone because such a classification of pedicle
breach may not be representative of clinical consequences
[4, 5, 10]. Therefore, until scientific evidence of a really
safe zone, accuracy in pedicle screw placement should
mean that the screw is completely contained within the
pedicle without any cortex violation.
For these reasons, various techniques have been
described for pedicle screw placement with established
clinical and radiological success to improve accuracy of
pedicle screws placement and reduce risk of pedicle
breaches.
The aim of this study is to provide an update based on
the literature review on current concepts in pedicle screws
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 Musculoskelet Surg

placement techniques and assessing risks and benefits

associated with each technique.

Pedicle screws placement techniques

The main concepts regarding pedicle screws placement and

different types of assistance in which the surgeon can refer
as an alternative to the freehand proceeding will be
reviewed in this section. Briefly, the insertion technique
can be divided as freehand and imaging-guided techniques.
The freehand technique can be performed as drill assisted
or by applying a pedicle gearshift probe. In freehand
technique, a final X-ray control should be performed to
confirm the proper positioning of the screws. Imaging-
guided techniques include fluoroscopic-assisted, intraop-
erative navigation and robotic-assisted surgeries.
Fig. 2 Representative depiction of an entry point in a thoracic
vertebra. The superior articular facet, the pars interarticularis and the
Entry points transverse process are, respectively, are represented in red, green and
blue colors. The entry point is located in the middle of the triangle
An exhaustive anatomical knowledge and the correct formed by these anatomical landmarks
identification of the main landmarks are the mainstay for a
the lower border of the superior articular facet and the
safe and reproducible pedicle screw positioning technique
medial border of the transverse process [11] (Fig. 2).
irrespective of which type of technique is used.
Passing from T12 to T7 the entry points are more medial
In the lumbar spine, the starting point is located at the
and cephalad, while above T7 are more lateral and caudal
junction between the pars interarticularis and the transverse
[12].
process immediately lateral to the mammillary process or
at the bisection of a vertical line through the facet joints
Insertion techniques
and a horizontal line through the transverse process
(Fig. 1). Removing the cortical bone over the entry point
Three main different insertion techniques (funnel, slide and
can show a canceolous bone which can help the surgeon to
in-out-in techniques) and two basic screw trajectory
find the pedicle [11].
(straightforward and anatomic) are described in literature
For S1, the starting point is located at the middle of the
[13–18].
line connecting the S1 dorsal foramen and the inferior
The funnel technique first described by Gaines [16]
portion of the S1 superior articular process.
utilizes a starting point within the transverse process, cre-
In the thoracic spine, the entry point is identified in the
ating a 6–10-mm hole in the posterior cortex providing a
middle of the triangle formed by the pars interarticularis,
direct way to safely apply pedicle screws at every level of
the spine.
The slide technique was introduced as a variation of the
funnel. In this technique, after the cancellous bone removal
the cortex of the anterior aspect of the transverse process is
used as a ‘‘slide’’ to reach the entry point on the pedicle
[15].
The third method known as the in-out-in is an
extrapedicular placement technique where a far lateral
entry point is used with a very convergent trajectory
passing through the transverse process and into the
vertebral body tangent to the pedicle. This technique is
occasionally preferred in case of severe deformity or
congenital small pedicle with high risk of medial pedicle
breach [4].
Fig. 1 Representative depiction of an entry point in a lumbar On the sagittal plane, two basic trajectories have been
vertebra. The starting point is located at the junction between the
described.
pars interarticularis and the transverse process

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Musculoskelet Surg
In the straightforward trajectory, the direction is parallel
to the superior endplate of the vertebral body. This tech-
nique allows the use of monoaxial pedicle screws and has
been related with higher pull-out strength.
Conversely, the anatomic trajectory is directed in a
cephalocaudal direction and parallel to the anatomical axis
of the pedicle. The entry point is located in a far cephalad
position with the projection of the axis of the pedicle to the
dorsal cortex of the superior articular facet used as direc-
tion reference. The anatomical trajectory, despite the least
resistance to pull-out, has been shown to be useful in sal-
vage situation wherein multiple screws positioning have
been tempted [13].
Freehand techniques: drill assisted and pedicle
gearshift (probe)
The creation of a pilot hole is the initial phase of every
pedicle screw insertion and it is of crucial importance since
it establishes the biomechanical relationship at the bone/
screw interface.
After the correct identification of the specific entry point
for the interested vertebra, the probe is placed at the base of
the cancellous soft spot indicating the pedicle entrance. A
slight ventral pressure is applied with the probe directed
laterally in order to avoid medial wall perforation. After
inserting approximately 15–20 mm, the probe is removed
and rotated by 180° to direct its tip medially inside the ver-
tebral body. Be sure to feel soft bone during the path without
any sudden advancement which could mean a pedicle
breaching. A ball-tipped pedicle feeler must be used during
each phase in order to palpate the five bony borders: the floor
and the medial, the lateral, the superior and the inferior wall.
Main advantage of the probe is related to the compacting
action on the bone. However, sometimes due to the bigger
size of probe respect to the finer insertion instruments like
drill, the pedicle wall penetration may lead to screw failure
due to bigger hole creation.
In the drill-assisted technique, the pilot hole can be
created by gentle advancement of the drill with low-speed
spins. In this way, the drill acts as a feeler finding the
smoothest way inside the pedicle. Main disadvantages are
related to the bone removal due to the drill effect and the
sharp point of the drill that could be cause of suddenly
damage to the adjacent structures. The drill made a smaller
hole compared with the probe, which eventually can pro-
vide better resistance of the screw and can also allow
multiple pedicle search attempts in case of severe pedicle
dysplasia.
Drill and probes are routinely used for pilot hole cre-
ation, but pros and cons between the use of one or the other
are not yet established in literature. Theoretically, the
creation of a hole of lesser diameter increases the quality of
the bone around and consequently enhancing the pull-out
resistance [19–21]. George et al. [22] found no differences
in pull-out strength values between the screws implanted
into drilled holes and those implanted into probed holes.
Similar results were later reported by Abrahão et al. [19]
who found that perforations with different instruments
presented similar results.
In case of drill-assisted pedicle screw insertion, it is
preferred to make the hole using a small-diameter drill in
order to increase the bone screw grip [20].
The freehand procedure generally requires a thorough
knowledge of the vertebral anatomy of each level of the
spine and an accurate preoperative planning. Practically
this technique has higher learning curve which can be
obtained by continuous practicing.
Imaging-guided techniques: fluoroscopic-assisted,
intraoperative navigation and robotic-assisted
surgeries
Tactile feedback and experience-based judgment are of the
utmost importance when using unassisted techniques. Even
for experienced surgeons, screw misplacement represents
one of the major concerns when performing spinal surgery
with reported screws misplacement rates from 5 to 41% in
the lumbar and from 3 to 55% in the thoracic spine [5–8].
With the aim to improve pedicle screw insertion accu-
racy, many different assisted techniques have been devel-
oped. They can be classified into three main categories:
fluoroscopic-assisted, intraoperative navigation and
robotic-assisted surgeries.
Fluoroscopic images are the most commonly used
because they provide useful 2D information regarding both
the entry point and the trajectory. Furthermore, image
intensifiers are easily accessible for the majority of the
operating rooms. Gelalis et al. [6] in a systematic literature
review found a rate of fully contained pedicle screws with
the aid of fluoroscopy ranging from 28 to 85%. Recently,
Mason et al. [23] reported an average accuracy of 68.1%
using conventional fluoroscopy. These results are compa-
rable with those obtained with freehand technique previ-
ously reported in literature [5–8], but the obvious
assistance of fluoroscopy when pedicle screw positioning is
unquestionably. To better evaluate intraoperative anatomy,
3D fluoroscopy has been developed using software able to
merge several consecutive fluoroscopic images from dif-
ferent angles. Despite an obvious radiation exposure
increase, accuracy rates have been reported to be improved
to 95.5% with using 3D fluoroscopy with consistently
higher values throughout all spinal level in comparison
with conventional fluoroscopy [23].
Intraoperative navigation surgery or computer-assisted
surgery (CAS) is based on the combined use of markers
123

and preoperative acquired imaging in order to guide the
surgeon on the patient’s anatomy in real time. Aim of these
procedures is to reduce errors making the techniques more
reproducible. Good-to-excellent results in terms of accu-
racy have been reported when applying intraoperative
navigation on pedicle screws placement. Ughwanogho
et al. [24] assessing placement accuracy on 547 thoracic
pedicle screws in 42 patients found significantly fewer
unsafe screw placement with Medtronic O-Arm CAS
compared with the freehand technique. Similarly, Verma
et al. [25] reported much better results for screw placement
with CAS navigation compared with freehand technique
with high statistical significance (p \ 0.00001). Despite the
encouraging results found by many authors, it is still under
debate whether accuracy improvement in pedicle screw
placement implies enhanced patient outcome [26]. More-
over, several potential disadvantages have been related to
CAS-like changes in geometry due to different position of
the patient in the preoperative template or during breaths.
Second, the renowned accuracy may be not so accurate due
to registration imprecision of the optical or electromagnetic
tracking systems [27].
Recently, a third type of assisted pedicle screw place-
ment has been developed: the robot-assisted surgery
(RAS). Some studies reported increased accuracy,
decreased potential surgical complications and reduced
intraoperative radiation exposure using this technique
[28–31]. However, a recent meta-analysis by Liu et al. [32]
reported no differences in the accuracy between robot-as-
sisted and conventional freehand pedicle screw placements
both in open and in percutaneous procedures. Nonetheless,
the authors themselves recognize the bitterness of this
technology acknowledging it a huge growth potential.
Conclusion
Pedicle screw placement remains one of the most chal-
lenging issues for spine surgeons especially in case of spine
deformity or anatomical variations particularly at the level
of the thoracic spine. However, the accuracy has improved
significantly by using imaging-assisted techniques. There
are many studies that support good results for each
described technique in which support the reliability and
reproducibility of these techniques. Imaging-guided pedi-
cle screw placement may provide a more precise trajectory
in case of anatomical variation and less skilled surgeons.
Freehand technique provides good results with shorter
surgical time and saving money for each surgery.
Despite different techniques available for pedicle screw
placement, we suggest the use of technique the surgeon is
more familiar with and which the surgeon has learned
during training period.
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Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
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