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Abstract: Background context: In pedicle screw fixation surgery, rigid instruments are inserted into a vertebral body. When the instruments are misdirected within the pedicle or advanced too far beyond it, perforations of the inner or outer cortex can cause damage to the spinal nerve roots and spinal cord. These complications can occur despite the use of imaging modalities, such as radiographs, fluoroscopy, and computerized axial tomography (CAT) scans. A-Mode ultrasound (US), a nonionizing modality, merits study for its possible use in such a type of surgery. Purpose: The purpose of the study was to determine the utility of A-mode US during pedicle screw placement, to characterize the approach to the marrow-cortex interface, and to obtain the signature profiles of cortex perforations. Study design: A-Mode data were generated on insertion of a forward-viewing transducer (FVT) and a side-viewing transducer (SVT) to successively greater drilled depths along the insertion pathway. A-Mode broadband US backscatter (BUB) pedicle screw emulation experiments were conducted with transducers inserted into drilled sheep vertebral bodies. BUB amplitude patterns were observed and analyzed. Descriptive statistics were used. Methods: In vitro acoustic experiments on vertebral bodies in a water bath were performed with two 1-MHz unfocused transducers to measure sound speed, broadband US attenuation, and backscatter coefficients. Micro-CAT scan three-dimensional (3-D) images of 10 disarticulated vertebral bodies were obtained pre- and postdrilling done in 5-mm depth increments with a flat-bottom drill. BUB patterns were noted of transducers inserted through rostral outer cortex, through the pedicle, and advanced to the ventral marrow-cortex interface. 2.5-MHz FVT and SVT were co-advanced in successive 5-mm increments along the insertion pathway, with BUBs measured at each point and the echoes composited into a single figure. Deliberate perforations of ventral cortex were made. Results: Evident patterns or measures indicating the proximity of the ventral marrow-cortex interface were: 1) marrow BUB values increasing in amplitude over three distal peaks in most FVT cases (7 out of 10) and SVT cases (9 out of 10); 2) BUB ratio of marrow-cortex interface to the smallest marrow value greater than 2, in all FVT cases (10 out of 10) with FVT mean of 4.00±1.82 (2.25–8.33); and 3) a ratio of distal BUB value to starting cortex BUB in the 0. 82 to 1.62 range (mean, 0.98±0.30) in 80% of FVT cases. Ventral FVT perforations resulted in a major drop in the BUB value. Conclusions: The increase in the BUB amplitudes in the distal insertion pathway suggests that, at least with a 2.5-MHz transducer, an approximate 1.5-cm US window exists in most cases, by which close approach of the ventral marrow-cortex interface could be anticipated. Other ratios may serve as stop criteria to prevent further drilling. A precipitous drop in BUB amplitude may be an indication of a cortex perforation. [Copyright &y& Elsevier]