The Journal of Spinal Surgery

Register      Login

VOLUME 3 , ISSUE 3 ( July-September, 2016 ) > List of Articles


Pedicle Screw Placement in the Thoracic and Lumbar Spine by the C-arm Guided Navigation and the Free Hand Method: A Technical and Outcome Analysis

Anantha Kishan, Anantha Gabbita, DN Varadaraju, Mohamed M Usman, Shivalinge G Patil, Amrut V Hosmath

Citation Information : Kishan A, Gabbita A, Varadaraju D, Usman MM, Patil SG, Hosmath AV. Pedicle Screw Placement in the Thoracic and Lumbar Spine by the C-arm Guided Navigation and the Free Hand Method: A Technical and Outcome Analysis. J Spinal Surg 2016; 3 (3):90-95.

DOI: 10.5005/jp-journals-10039-1098

Published Online: 01-09-2012

Copyright Statement:  Copyright © 2016; The Author(s).



The use of pedicle screws in stabilizing all three columns of the spine is a well-known but technically demanding procedure. Various assisted techniques like intraoperative fluoroscopy and stereotaxy-guided techniques have marginally increased placement accuracy along with increased radiation exposure to the surgeon and the patient, with an increased operative time.

Over the last two decades, a detailed understanding of the anatomy of the thoracolumbar pedicles has led to the emergence of the “free-hand” technique.


To analyze the pedicle screw placement in thoracic, lumbar, and sacral spine over a 3-year period in terms of the intraoperative and immediate postoperative procedural results using navigation-guided and free hand techniques.

Materials and methods

A retrospective study was done over a period of 3 years from November 2012 to December 2015 in a tertiary care center by a single surgeon, involving 118 cases that were done using the C-arm navigation and the free hand technique.


The study involved a total of 118 patients and 546 screws over a period of 3 years. The indications consisted of degenerative diseases (72%), infection (12.7%), trauma (12.7%), and malignancy (2.54%). The initial 77 cases were done by image guidance under C arm navigation and the later 41 cases with free hand techniques. Among these, there were eight breaches noted (6.72%), five (6.49%) in the image-guided technique vs three (7.3%) in the freehand technique. The direction of breach was lateral in one case (12.5%) and medial in seven cases (87.5%). Three patients (37.5%) with suboptimal screw placement underwent revision surgery. Four patients (3.36%) in the present study had postoperative neurological deficit in the form of foot drop and preoperative durotomies noted in nine patients (7.62%). Postoperative surgical site infections were noted in four cases (3.38%).


Free hand pedicle screw placement based on external anatomy alone can be performed with acceptable safety and accuracy in experienced hands and allows avoidance of radiation exposure encountered in fluoroscopic techniques.

How to cite this article

Gabbita A, Usman MM, Kishan A, Varadaraju DN, Patil SG, Hosmath AV. Pedicle Screw Placement in the Thoracic and Lumbar Spine by the C-arm Guided Navigation and the Free Hand Method: A Technical and Outcome Analysis. J Spinal Surg 2016;3(3):90-95.

PDF Share
  1. A method of spinal fusion. J Bone Joint Surg Br 1959;41-B(2):248-259.
  2. Plating of thoracic, thoracolumbar and lumbar injuries with pedicle screw plates. Orthop Clin North Am 1986 Jan;17(1):147-159.
  3. Stereotactic navigation for placement of pedicle screws in the thoracic spine. Neurosurgery 2001 Apr;48(4):771-778.
  4. Computer-assisted fluoroscopic navigation of pedicle screw insertion: an in vivo feasibility study. Acta Orthop Scand 2004 Dec;75(6):730-735.
  5. Comparative results between conventional and computer-assisted pedicle screw installation in the thoracic, lumbar, and sacral spine. Spine (Phila Pa 1976) 2000 Mar;25(5):606-614.
  6. Computer-assisted fluoroscopic targeting system for pedicle screw insertion. Neurosurgery 2000 Oct;47(4):872-878.
  7. Three-dimensional fluoroscopy-guided percutaneous thoracolumbar pedicle screw placement. Technical note. J Neurosurg. 2003 Oct;99(3 Suppl):324-329.
  8. Accuracy of free-hand pedicle screws in the thoracic andLumbarspine: analysis of 6816 consecutive screws. Neurosurgery 2011 Jan;68(1):170-178.
  9. Thoracolumbar spine trauma: Evaluation and surgical decision-making. J Craniovertebr Junction Spine 2013 Jan;4(1):3-9.
  10. Thoracolumbar Injury Classification and Injury Severity Score System: a Literature Review of Its Safety. Global Spine J 2016 Feb;6(1):80-85.
  11. Techniques and accuracy of thoracolumbar pedicle screw Placement. World J Orthop 2014 Apr;18:5(2):112-123.
  12. Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques. Eur Spine J 2012 Feb;21(2):247-255.
  13. Accuracy and postoperative assessment of pedicle screw placement during scoliosis surgery with computer-assisted navigation: a metaanalysis. Int J Med Robot 2016;Mar 8.
  14. Accuracy of pedicle screw insertion using fluoroscopy-based navigation-assisted surgery: computed tomography postoperative assessment in 96 consecutive patients. J Korean Neurosurg Soc 2014 Jul;56(1):16-20.
  15. Pedicle screw placement in the thoracic spine: a comparison study of computer-assisted navigation and conventional techniques. Orthopedics 2010 Aug;33(8):14.
  16. Free hand pedicle screw placement in the thoracic spine: Is it safe? Spine (Phila Pa 1976) 2004 Feb;29(3):333-342.
  17. Free-hand technique for thoracolumbar pedicle screw instrumentation: critical appraisal of current “State-of-Art”. Neurol India 2009 Nov-Dec;57(6):715-721.
  18. Free-hand thoracic pedicle screws placed by neurosurgery residents: A CT analysis. Eur Spine J 2010 May;19(5):821-827.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.