Insertion of pedicle screws

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 Pedicle screw entry points
 Screw insertion
Pedicle screw entry points

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Lumbar spine
The entry point of the pedicle screw is defined as the confluence of any of the four lines: 
Pars interarticularis
Mamillary process
Lateral border of the superior articular facet
Mid transverse process

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Thoracic spine
The entry point of the pedicle screw for the lower thoracic segments is defined after determining the
intersection of the mid portion of the facet joint and the superior edge of the transverse process. The
specific entry point will be just lateral and caudal to this intersection. 
The entry point tends to be more cephalad as one moves to more proximal thoracic levels. 
Landmarks:
Lateral border of the superior facet
Lateral border of the inferior facet
Ridge of the pars interarticularis and the transverse process
Screw insertion

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Opening of the cortex
Open the superficial cortex of the entry point with a burr or a rongeur.

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Cranial-caudal angulation
A pedicle probe is used to navigate down the isthmus of the pedicle into the vertebral body.
The appropriate trajectory of the pedicle probe in the cranial caudal direction occurs by aiming for the
contralateral transverse process.
Thereby paralleling the screws to the superior endplate.

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Medio-lateral inclination
The medio-lateral inclination will depend on the rotation of the vertebra. The main goal is to avoid medial
penetration of the spinal canal superficially and lateral or anterior penetration of the vertebral body
cortex at the depth of insertion. Ideally, the two screws should converge but stay entirely within the
cortex of the pedicles and body.

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Screw insertion
Once the pedicle track has been created, it is important to confirm a complete intraosseous trajectory by
pedicle and body palpation using a pedicle sounding device. At any point in the process, radiographic
confirmation can be obtained.

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An appropriate diameter and length screw is carefully inserted into the same trajectory created.