Lesions of the pedicles and posterolateral part of the vertebral body are more easily reached via a transpedicular route (Fig. 7). The patient is placed in prone position under posteroanterior fluoroscopy. The X-ray beam is tilted to profile the pedicles. The skin puncture point is usually situated 5 mm above and lateral to the superolateral corner of the pedicle. However, this will be adapted to precise location of the lesion to reach in the vertebral body. The needle track will be more oblique (more toward the midline) if the skin-puncture point is more lateral (up to 15 mm lateral to the pedicle). After local anesthesia, a direct approach BTN (M1 or M2 Cook, Manan, LAR 1000) is inserted posteriorly toward the pedicle in a slight medial and caudad direction. Bone is abutted at the superolateral outer cortex of the pedicle (Figs. 7 and 8). Then the needle
FIGURE 9 Posterolateral approach to the thoracic spine drawn on a computed tomography picture. Note that puncture site (A) is 5 cm from the midline and the angle of approach (BAC) is close to 55° from the coronal plane and needle path between pleura and spinal canal.
crosses the pedicle toward its medial cortex. In any case, the needle tip should not cross the medial cortex of the pedicle on the anteroposterior view before it reaches the posterior cortex of the vertebral body on a lateral view. The transpedicular approach may be more difficult at the upper lumbar level where the pedicles may be very thin.
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