A, Safe placement of segmental pedicle screws is essential. The starting point must never be medial to the midpoint of the superior facet. (Redrawn from Medtronic Sofamor Danek USA, Inc., Memphis, Tenn, with permission.)

B, Using the straightforward approach, the thoracic vertebral cephalad–caudad starting points vary slightly depending on the levels being instrumented. TP, Transverse process. (Redrawn from Medtronic Sofamor Danek USA, Inc. Memphis, Tenn, with permission.)

C, 1 and 2: Preparation for the pedicle screw sites should begin at the most distal vertebra to be instrumented and proceed cephalad. Either the freehand technique or the fluoroscopy-guided technique can be used. A thoracic gearshift (2-mm blunt-tipped curved pedicle finder) is used to enter the pedicle.

3: To avoid medial wall penetration, the gearshift is initially pointed laterally when the pedicle is entered.

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