C2-C3 anterior cervical discectomy: Anatomical considerations and outcomes.

INTRODUCTION: Anterior cervical discectomy and fusion (ACDF) at C2-C3 is technically demanding due to complex neurovascular anatomy and limited surgical access. Comprehensive anatomical guidance for this approach remains limited. We provide a detailed anatomical review of the anterior approach to C2-C3 and present institutional clinical outcomes for this procedure across a range of indications. MATERIALS AND METHODS: A comprehensive literature review was synthesized with surgical experience to describe relevant anatomy and technical considerations for C2-C3 ACDF. In this retrospective series, patient demographics, operative details, complications, and outcomes were analyzed for patients undergoing ACDF, including C2-C3 at our institution. RESULTS: Eight patients (75% female, mean age: 60.6) underwent ACDF, including C2-C3 between 2022 and 2025. Indications included proximal junctional failure, trauma, infection, rheumatoid arthritis, and degenerative myelopathy. Fusions ranged from single-level C2-C3 to multilevel C2--C7 constructs. Mean operative time was 78.9 min with mean blood loss of 21.9 cc. Complications occurred in 37.5% of patients, including persistent dysphagia (n = 2) and failed extubation (n = 1). No direct neurovascular injuries occurred. Mean length of stay was 16.4 days. CONCLUSIONS: ACDF at C2-C3 requires mastery of anatomy, including positioning, sequential dissection, and identification of neurovascular structures. Careful attention to anatomical principles allows this procedure to be performed safely without producing specific neurovascular injury, although dysphagia and airway-related morbidity remain common complications. This work provides practical strategies for navigating this challenging level.