MOJ
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Review Article Volume 18 Issue 5
Does cortical violation improve pedicle screw fixation? a narrative review of the biomechanical evidence
Dr Pablo Martínez-Soler, Dr Juan F Martínez-Canca
Received: September 01, 2026 | Published: September 15, 2026
Citation: Martínez-Soler P, Martínez-Canca JF. Does cortical violation improve pedicle screw fixation? a narrative review of the biomechanical evidence. MOJ Orthop Rheumatol. 2026;18(4):157-163. DOI: 10.15406/mojor.2026.18.00758
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
©2026 Martínez-Soler, et al. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.
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