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Related Experiment Video

Updated: Sep 14, 2025

Clinical Application of Microscope-Assisted Minimally Invasive Anterior Lumbar Interbody Fusion
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Upper-Level Instrumentation at C2 Versus C3 Does Not Influence Radiographic or Clinical Outcomes After Posterior

Mark A Plantz1, Jeremy Marx1, Tyler Compton1

  • 1Department of Orthopaedic Spine Surgery, Northwestern University, Chicago, IL.

Clinical Spine Surgery
|July 21, 2025
PubMed
Summary

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Clinical Outcomes Following Three- and Four-Level Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis.

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The Journal of the American Academy of Orthopaedic Surgeons·2026

Choosing the upper instrumented vertebra (UIV) at C2 versus C3 for posterior cervical decompression and fusion (PCDF) did not significantly impact clinical or radiographic outcomes in patients with cervical myelopathy. This suggests C2 instrumentation complexity is not critical for successful PCDF results.

Area of Science:

  • Neurosurgery
  • Orthopedic Surgery
  • Spinal Surgery

Background:

  • Posterior cervical decompression and fusion (PCDF) is a standard treatment for multilevel cervical spondylotic myelopathy.
  • Optimal placement of the upper instrumented vertebra (UIV) at C2 versus C3 remains debated due to limited evidence.

Purpose of the Study:

  • To compare clinical and radiographic outcomes between patients undergoing PCDF with UIV at C2 versus C3.
  • To determine if UIV level influences surgical success in cervical myelopathy treatment.

Main Methods:

  • Retrospective cohort study of adult patients undergoing PCDF for cervical myelopathy between 2014 and 2019.
  • Inclusion criteria: UIV at C2 or C3, lower instrumented vertebra (LIV) at or above T2, and minimum 2-year follow-up.
  • Exclusion criteria: pediatric, revision, staged procedures, or non-degenerative indications.
Keywords:
cervical sagittal alignmentcervical spondylotic myelopathyclinical outcomes in spine surgeryposterior cervical decompression and fusionposterior cervical fusionradiographic outcomes in spine surgeryspine surgeryspondylosissubaxial fixationupper instrumented vertebra

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Main Results:

  • 135 patients included: 47 (34.8%) with UIV at C2 and 88 (65.2%) with UIV at C3.
  • No significant differences in 90-day readmission or 2-year reoperation rates between C2 and C3 UIV groups.
  • Similar mean changes in cervical sagittal vertical axis (cSVA), T1 slope, cervical lordosis (CL), T1 slope-CL (TS-CL), and C0-C2 angles; multivariate analysis showed no UIV correlation with radiographic outcomes.

Conclusions:

  • No significant difference in clinical or radiographic outcomes was observed between the C2 and C3 UIV groups.
  • The increased complexity of C2 instrumentation does not appear critical for achieving successful outcomes in PCDF for cervical myelopathy.
  • Surgical decision-making for UIV level in PCDF may not require prioritizing C2 over C3 based on these findings.