Alignment of pedicle screws with pilot holes: can tapping improve screw trajectory in thoracic spines?

Pedicle screws are placed using pilot holes. The trajectory of pilot holes can be verified by pedicle sounding or radiographs. However, a pilot hole alone does not insure that the screw will follow the pilot hole. No studies have characterized the risk of misalignment of a pedicle screw with respect to its pilot hole trajectory. The objective of this study was to measure the misalignment angles between pedicle screws and pilot holes with or without tapping. Six human cadaveric thoracic spines were used. One hundred and forty pilot holes were created with a straight probe. Steel wires were temporarily inserted and their positions were recorded with CT scans. The left pedicles were tapped with 4.5 mm fluted tap and the right pedicles remained untapped. Pedicle screws (5.5 mm) were inserted into the tapped and untapped pedicles followed by CT scans. The trajectories of pilot holes and screws were calculated using three-dimensional vector analysis. A total of 133 pilot holes (95%) were inside pedicles. For the untapped side, 14 out of 68 (20%) screws did not follow the pilot holes and were outside the pedicles. For the tapped side, 2 out of 65 (3%) did not follow and breached the pedicles. The average misalignment angles between the screw and pilot hole trajectory were 7.7° ± 6.5° and 5.6° ± 3.2° for the untapped side and tapped side, respectively (P < 0.05). Most pedicle screws had lateral screw breach (13 out of 16) whereas most pilot holes had medial pedicle breach (6 out of 7). Tapping of pilot holes (1 mm undertap) helps align pedicle screws and reduces the risk of screw malposition. Although most pedicle screws had lateral breach, the risk of medial pedicle breach of the pilot holes must be recognized.