More than half of traumatic spinal cord injuries happen in the neck, so cervical stabilization is the operation most people on this site have had. It is also the region with the most ways to do it: from the front, from the back, from both, or with no surgery at all. This guide walks the neck from the skull down, explains each option in plain language, and is honest about what every one of them costs in movement. For the full spine, start with the overview of fusion and stabilization.

The Neck, Level by Level

  • Occiput (C0): the base of the skull. The joint between the skull and C1 does about half of your nodding.
  • C1, the atlas: a ring of bone with no vertebral body, sitting under the skull.
  • C2, the axis: has a peg of bone called the dens or odontoid that sticks up into the ring of C1. C1 pivots around it. This one joint provides roughly half of all head rotation.
  • C3–C7, the subaxial spine: "normal" vertebrae stacked with discs between them and paired facet joints behind. Most traumatic cervical SCIs happen here, especially C4–C6.
  • C7–T1, the cervicothoracic junction: where the mobile neck meets the stiff, rib-braced upper back. Constructs that end here are under extra stress, so surgeons often extend them to T1 or T2.

Two things make the neck harder to instrument than the rest of the spine: the bones are small, and the vertebral arteries run up through holes in the sides of C1–C6 on their way to the brain. Screw choices in the neck are mostly about staying away from those arteries.

How Surgeons Decide

Three questions drive the plan: Is the cord being compressed, and from which side? Is the column unstable (broken bone, torn ligaments, dislocated facets)? And what is the neurological exam? The SLIC score (Subaxial Cervical Spine Injury Classification) formalizes this: injury shape, ligament damage on MRI, and neurological status each add points, and a high score means surgery. A spinal cord injury adds the most points of anything.

When surgery is needed, current guidance recommends decompressing the cord within 24 hours when it can be done safely, including for central cord syndrome. Choosing the front or the back comes down to where the pressure is: a disc or bone fragment in front of the cord is usually cleared from the front; a long stretch of narrowing, dislocated facets, or an unstable back column is usually handled from behind; the worst injuries get both.

Collars, Halos & Traction

  • Rigid collars (Miami J, Aspen Vista, Philadelphia) limit but do not eliminate neck motion. Stable fractures without cord injury are often treated in a collar alone for 6–12 weeks. After a fusion, a collar protects the construct while the bone heals; how long varies from a couple of weeks to three months depending on the surgeon and how solid the hardware felt. Collars cause their own problems in SCI: skin breakdown under the chin, over the collarbones, and at the back of the head, especially in someone who cannot feel or shift the pressure. Padding changes and daily skin checks matter.
  • Halo vest: four pins tightened into the outer skull hold a metal ring, which connects by uprights to a padded vest. It is the most rigid brace there is and can substitute for surgery in some C1 and C2 fractures, including many odontoid fractures in younger people. Downsides: pin-site infection and loosening, pressure sores under the vest, difficulty with hygiene, and enough breathing and swallowing trouble in older adults that most centers avoid it after roughly age 65. It stays on 8–12 weeks.
  • Traction with Gardner-Wells tongs: two pins in the skull, weights on a pulley. Used early to pull a dislocated facet joint back into position ("closed reduction") and keep the neck aligned until surgery. Sometimes a reduction in traction is enough to decompress the cord within hours, well before the operating room is ready.

Skull Base, C1 & C2

Injuries here are less common after traumatic SCI because high cord injuries at this level are often fatal at the scene, but they happen, especially in older adults and in falls.

  • Odontoid (dens) screw: for certain fractures through the base of the dens, a single screw is passed up from the front of C2 into the peg to hold it while it heals. It preserves C1–C2 rotation, which is why it is attractive, but it needs good bone and the right fracture angle.
  • Atlantoaxial (C1–C2) fusion: locks the pivot joint. The modern standard is the Harms/Goel technique: screws into the lateral masses of C1 and the pars or pedicles of C2, joined by rods. The older Magerl transarticular screw passes one long screw diagonally across the joint on each side. Both fuse reliably; both cost most of your head rotation, because this is the joint that does it.
  • Occipitocervical fusion: a plate screwed to the back of the skull, connected by rods to screws in C2 and sometimes lower. Used when the joint between skull and C1 is unstable, or when C1 is too damaged to hold a screw. This is the stiffest neck construct of all: almost no nodding or rotation in the upper neck. Surgeons fix the angle of the head carefully before locking the rods, because you will live with that angle. People with occipitocervical fusions learn to turn from the shoulders and to position screens and mirrors accordingly.

From the Front: ACDF & Corpectomy

The front of the neck is reached through a short horizontal incision, usually on the left, moving the windpipe and esophagus one way and the carotid artery the other. Surgeons like this route because it is muscle-sparing and goes straight to discs and vertebral bodies, which is where most pressure on the front of the cord lives.

  • ACDF (anterior cervical discectomy and fusion): the single most common spine operation. The disc is removed, any bone spurs or fragments pressing on the cord are cleared, a cage (PEEK plastic, titanium, or a block of donor bone) packed with graft is set into the empty space, and a small anterior plate is screwed across the two vertebrae. One-level ACDF is a modest operation. Two- and three-level ACDFs are done routinely; beyond that most surgeons add a posterior construct because long anterior plates fail more often.
  • ACCF (anterior cervical corpectomy and fusion): when a vertebral body is burst or when bone behind the body is pressing on the cord over more than one disc, the whole body is removed and replaced with a strut: an expandable titanium cage, a mesh cage packed with bone, or a block of bone from the fibula or the iliac crest. A plate spans from the body above to the body below. Multi-level corpectomies are usually backed up with posterior screws and rods, because a long strut with a plate alone can pull loose.
  • Anterior reduction of a facet dislocation: sometimes a locked facet can be unlocked from the front by removing the disc and levering the vertebrae, then plating them. If it will not reduce, the surgeon goes around to the back.
  • Cervical disc replacement (arthroplasty): a moving artificial disc instead of a fusion. You will see it advertised. It is for degenerative disc disease in a stable spine, not for fractures, dislocations, or torn ligaments, so it is almost never the right tool after a traumatic SCI. Worth knowing so you understand why nobody offered it.

From the Back: Lateral Mass Screws & Rods

A midline incision down the back of the neck, muscles peeled off the bone, and the spine exposed from behind. This is the approach for long constructs, for unstable back columns, and for decompressing a cord that is being squeezed over several levels.

  • Posterior cervical fusion (PCF) with lateral mass screws: at C3 through C6, a screw goes into each lateral mass, the small block of bone beside the facet joint, angled up and outward to stay clear of the vertebral artery and nerve root. Two rods are contoured to the neck and locked into the screws. At C2 the surgeon uses a pars, pedicle, or translaminar screw, because C2 has thicker bone to grab. At C7 and T1, pedicle screws are common. The facets are scraped raw and packed with bone graft so they fuse. My C2–C7 construct is exactly this: lateral mass screws at C3–C6, stronger anchors at the top and bottom, two rods.
  • Laminectomy and fusion: the lamina (the bony roof) is removed at the compressed levels to free the cord, and because removing it destabilizes the spine, the screw-and-rod fusion is done at the same time. This is the standard operation for multi-level compression from behind, and the one most often paired with a cervical SCI. It carries the highest rate of C5 palsy (see Risks).
  • Laminoplasty: instead of removing the lamina, the surgeon cuts a hinge on one side and a full cut on the other, swings the roof open, and props it with tiny plates. The canal is bigger and nothing is fused. It is a good operation for chronic narrowing (cervical myelopathy, OPLL) in a stable, well-aligned neck. It is rarely used for trauma, because an unstable spine needs a fusion, not a hinge.
  • Posterior foraminotomy: a keyhole enlargement of the opening where one nerve root exits. Not a stabilizing operation, but sometimes added to a fusion to free a pinched root, or done later to treat C5 palsy that is not recovering.
  • Wiring and cables: before screws, posterior cervical fusions were held with wires looped under the lamina or around the spinous processes. You will still see this in older people's histories and occasionally as a supplement in children.
  • Minimally invasive posterior cervical fusion: one- or two-level facet fusions done through tubes or small incisions with facet screws or cages. Not typically for the long, unstable constructs SCI tends to need.

Front and Back Together

For fracture-dislocations, burst fractures with a torn back column, multi-level corpectomies, and fusions that cross the cervicothoracic junction, the surgeon does both: clear and reconstruct the front, then screw and rod the back. This can be one long operation with the patient repositioned, or two operations a day or two apart. A "360" or circumferential fusion is the most stable construct you can build and usually means a shorter time in a collar, at the cost of a bigger recovery.

What Each Fusion Costs in Motion

Nobody sat me down and explained this, so here it is. A normal neck can nod through roughly 60° of forward bend and 60–70° backward, turn about 80° to each side, and tilt about 45° each way. The joints share that work unevenly:

  • Skull to C1 does most of the nodding "yes."
  • C1–C2 does about half of the turning "no."
  • C3–C7 share the rest, with C4–C5 and C5–C6 the most mobile segments for bending, which is exactly why they get injured most.

So the losses look like this in practice:

  • One- or two-level ACDF (say C5–C6): most people cannot tell the difference within a year. Neighboring levels pick up the slack, which is also why they wear faster.
  • C1–C2 fusion: the rest of the neck still nods well, but turning to check a blind spot drops by about half and you learn to turn your torso.
  • Occipitocervical fusion: the head is essentially fixed to the top of the neck. Rotation comes from the lower neck and the shoulders; nodding is limited.
  • Long subaxial fusion (C2–C7, C3–T1, and similar): most of the nodding and side-bending from the lower neck is gone, but because C1–C2 is not fused, you keep most of your rotation. Looking down at your lap, checking your feet on the footplate, and tucking your chin to swallow are the daily differences. Tilting the wheelchair back and raising work surfaces and screens toward eye level make a real difference.

One long-term study of people with traumatic cervical SCI treated with anterior fusion found that neck mobility years later depended more on the number of levels fused than on anything else. Fewer levels, more motion, but only if fewer levels was safe.

Neck-Specific Risks

The general risks of any fusion (infection, bleeding, clots, pseudarthrosis, hardware loosening) are covered in Living With Spinal Hardware. These are the ones particular to the neck:

  • Swallowing trouble (dysphagia) after anterior surgery. Very common in the first days because the esophagus was pulled aside; it usually fades within weeks. A small number of people have persistent trouble, especially after multi-level surgery or a thick plate. Speech-language pathologists can help. It matters doubly if you already have a tracheostomy or a weak cough after a high injury.
  • Hoarseness from stretching the recurrent laryngeal nerve during an anterior approach. Usually temporary.
  • C5 palsy. New weakness of the deltoid and biceps (shoulder lift, elbow bend) appearing one to eight days after surgery, on one or both sides. It follows about 4% of anterior operations, about 5% of laminoplasties, and roughly 12% of posterior laminectomy-and-fusion operations. The leading theory is the cord shifting backward once it is freed and tugging the C5 root. Most people recover over three to six months, but around a fifth are left with some weakness, and in someone with a cervical SCI who is counting on those muscles for transfers, that is not a small thing. Ask what the plan is if it happens. If a new deficit after surgery is bigger than one shoulder, read Paralyzed After Spine Surgery.
  • Vertebral artery injury. Rare, but it is why lateral mass screws are short and angled outward and why some surgeons image the arteries before placing C2 screws.
  • Adjacent segment disease. The classic study found about 3% of ACDF patients per year develop new symptoms at a neighboring level, adding up to roughly a quarter of people within ten years. Long constructs push the same stress to the junctions above and below. For me, the levels to watch are C1–C2 above and C7–T1 below.
  • Hardware at the cervicothoracic junction. Constructs ending at C7 fail more often than ones extended to T1 or T2, which is why surgeons argue about where to stop.
  • Loss of alignment (kyphosis). A neck fused in a forward-tipped position, or one that drifts forward at the junction, leads to a "chin on chest" posture that affects swallowing, breathing, and horizontal gaze. Good sagittal alignment at the time of surgery is the main protection.

Recovery in a Collar

  • Expect the collar for anywhere from two weeks to three months. Ask specifically whether you may remove it to shower and how to do skin checks under it. In a wheelchair, a collar changes your center of gravity and your ability to look down at your hands, which affects early transfers and pressure reliefs.
  • Rehab starts in the collar. Therapists work around it; ask them and the surgeon to agree on what "neck precautions" mean in writing, because the two teams do not always say the same thing.
  • Sleep is the hardest part for most people. A wedge or a hospital-bed head lift helps more than pillows.
  • Driving is usually off-limits until the collar is gone and you can check blind spots. For long fusions, wide-angle and blind-spot mirrors become permanent equipment. See adaptive driving.
  • Follow-up X-rays are typical at about 6 weeks, 3 months, and 6–12 months, sometimes with a CT to confirm bridging bone.

Questions to Ask

  • Which levels did you fuse, and which did you decompress? Did you remove any lamina?
  • What screws did you use at each level (lateral mass, pedicle, pars), and what diameter rods?
  • How much rotation and flexion should I expect to keep, and what does that mean for driving?
  • What is the plan if I develop C5 weakness?
  • How long in the collar, and can I remove it for skin care and showering?
  • Do I need imaging of my vertebral arteries, and are they intact?
  • Is my hardware safe for MRI at 3T? I will need spinal MRIs for the rest of my life.

Sources & Further Reading

This is not medical advice. Spine surgery decisions depend on the exact fracture pattern, your neurological exam, your bone quality, and your overall health. The names and techniques here are to help you understand and question what your surgical team proposes, not to replace that conversation. Practice varies by surgeon and institution.

Related reading

Medical
Spinal Fusion & Stabilization: The Full Map
Medical
Living With Spinal Hardware
Medical
Central Cord Syndrome
Medical
What to Expect by Injury Level

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Written with lived SCI experience and clinical evidence. Not medical advice. · Last reviewed September 2026