Aims: Pedicle screws are mechanically superior to conventional fixation techniques in the thoracic spine, but because of safety concerns their use have been limited and rejected by many surgeons on anatomical grounds. Aims of this lecture are to present a literature review and an audit of our own experience. Methods: The recent literature was reviewed to find anatomical and biomechanical studies and clinical reports. Records of patients at our department, where thoracic pedicle screws have been used since 1996 for trauma, tumour, deformity and infection cases were examined for complications related to instrumentation. Results: All biomechanical studies show superior performance of thoracic pedicle screws in comparison to hooks, sublaminar wires or anterior screw constructs. Some cadaver and CT studies show that placement of pedicle screws may cause serious injury to neurovascular structures. However, clinical reports from different institutes around the world show a low complication rate directly related to the use of thoracic pedicle screws. In our own patient population we did not find any serious neurovascular complications, either. Three times, CSF leakage during screw placement was reported without further consequences. No neurologic deficits or injury to major blood vessels have been seen. Conclusions: Despite the theoretical risks it seems that pedicle screws can be placed safely in the majority of thoracic vertebrae even in scoliotic deformities. Thorough knowledge of thoracic spine anatomy and extensive experience with lumbar and thoracolumbar junction pedicle screw placement is necessary to prevent possible devastating complications.