Abstract

The belief that cortical breach during pedicle screw insertion may enhance biomechanical stability persists in some surgical settings, largely owing to misinterpretation of bicortical fixation principles and anecdotal experience. This focused narrative review critically examines the biomechanical and clinical evidence addressing whether cortical violation improves pedicle screw stability. Available evidence indicates that fixation strength primarily depends on controlled cortical engagement and preservation of the bone-implant interface rather than on cortical breach. Selected biomechanical studies suggest that controlled bicortical engagement may increase fixation strength in specific circumstances, particularly in compromised bone quality; however, this should be distinguished from unintended or excessive cortical violation. Cortical breach has been associated with loss of pedicular containment, reduced fixation strength in experimental models, and increased neurovascular and visceral risk. Overall, the available evidence does not support cortical violation beyond anatomical boundaries as a routinely advantageous biomechanical or clinically justifiable strategy.

Keywords

fixation