BACKGROUND Pedicle screw fixation is considered biomechanically superior to other stabilization constructs. However, the potential for severe complications have discouraged its use in the thoracic spine. Our goal is to determine the incidence of major perioperative complications following the placement of thoracic pedicle screws using anatomic landmarks and intraoperative fluoroscopy in patients with spine fractures. METHODS Retrospective review of 245 consecutive patients with spine fractures requiring pedicle screw fixation between T1 and T10 at a regional Level I trauma center between 1995 and 2001. Database and medical record review were used to identify the incidence of major perioperative complications. A major complication was defined as a potentially life-threatening vascular injury, neurologic deterioration, pneumothorax or hemothorax, and tracheoesophageal injury. Patients were monitored for these complications from the time of surgery until discharge. RESULTS In all, 1,533 pedicle screws were placed between T1 and T10 in 245 patients. No patient sustained a major complication related to screw placement. Three patients (1.2%) required a secondary procedure for prophylactic revision of four (0.26%) malpositioned screws. CONCLUSIONS This study supports the safety of pedicle screws in the thoracic spine using preoperative imaging evaluation, standard posterior element landmarks and intraoperative fluoroscopy.