Zero-profile interbody fusion in single and two-level anterior cervical discectomy and fusion: a novel surgical system and its indications

Abstract

Anterior cervical discectomy and fusion (ACDF) is considered gold standard for anterior management of cervical degenerative disease, yet traditional interbody and plate constructs often require substantial soft-tissue exposure and may be associated with increased postoperative morbidity and dysphagia/prevertebral swelling. Moreover, anterior plate prominence and prolonged retraction have been implicated in postoperative dysphagia and prevertebral soft-tissue irritation, motivating interest in low-profile fixation strategies. The goal of this paper is to introduce a novel zero-profile interbody fusion technology and describe its clinical application in the context of 1- and 2-level ACDF. Specifically, this paper aims to: (I) define indications for use of this novel zero-profile interbody fixation system; (II) detail the step-by-step surgical technique with tips/tricks and other technical pearls; and (III) discuss advantages of this system relative to traditional interbody devices and plate-based constructs. Overall, this novel implant combines a biocompatible polymer interbody spacer with integrated titanium fixation, enabling stable anterior column support and an all-in-one construct designed to remain fully contained within the disc space footprint while maintaining construct stability and arthrodesis principles. Overall, this novel technique enables efficient intraoperative implantation, reduced soft-tissue retraction, especially in revision cases that conventionally necessitate plate removal or in adjacent-segment settings where prior anterior hardware may complicate exposure. Because this report is intended as a surgical technique description rather than a clinical outcomes study, any proposed benefits related to dysphagia, operative time, or fusion should be interpreted cautiously and warrant prospective comparative evaluation. Overall, it represents a safer, quicker and easy-to-adopt advancement in anterior cervical fusion technology that may streamline workflow while minimizing anterior profile.

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Surgical highlights

• This manuscript describes a step-by-step surgical technique for anterior cervical discectomy and fusion (ACDF) using a true zero-profile interbody fusion system (SABER-C) with integrated fixation contained entirely within the implant footprint.

• Key technical features include inline implantation, integrated locking, and optional pre-loaded spike fixation, allowing secure stabilization without a separate anterior cervical plate.

What is conventional and what is novel/modified?

• Conventional ACDF typically utilizes a separate interbody cage and anterior cervical plate, which often requires wider exposure, plate sizing, and additional soft-tissue retraction.

• The novel approach described here eliminates the need for a separate anterior plate by combining a biocompatible polymer interbody spacer with integrated titanium fixation and internal locking.

• Pre-loaded spike fixation enables rapid stabilization without pilot holes, potentially streamlining workflow and facilitating implantation through a smaller surgical corridor, particularly in revision or adjacent-segment cases.

What is the implication, and what should change now?

• This technique provides surgeons with a plate-free, zero-profile ACDF option that may simplify implantation, reduce anterior hardware prominence, and improve efficiency in anatomically constrained or revision settings.

• SABER-C may be especially useful for one- and two-level ACDF, adjacent segment disease, and cases where minimizing operative steps and anterior soft-tissue manipulation is desirable.

• While clinical outcome benefits remain inferential, this technique offers a reproducible, easy-to-adopt alternative to traditional plate-based constructs and warrants further prospective comparative study.

Introduction

Anterior cervical discectomy and fusion (ACDF) is a commonly performed anterior-based procedure for management of cervical spine pathology, performed 170,000 annually in the United States for management of cervical radiculopathy and/or myelopathy (1,2). Traditional ACDF constructs utilize a separate interbody cage and anterior cervical plate, providing solid stability and overall high rates of arthrodesis (3,4). While ACDF has an outstanding track record, it has been shown in the literature that prominence of the anterior plate potentially contributes to postoperative dysphagia, esophageal irritation, and/or prevertebral soft-tissue swelling (5-7). Furthermore, anterior plating has been associated with adjacent segment degeneration and technical challenges in the context of revision surgery, especially in cases necessitating plate hardware removal and construct extension (8).

To this end, zero-profile interbody fusion systems were developed in part to mitigate these issues by integrating the fixation mechanism directly into the interbody cage and eliminating the need for a separate anterior plate (9). In contrast to earlier stand-alone cages that rely solely on screw-based fixation, the SABER-C system incorporates integrated fixation and an internal locking mechanism entirely within the implant footprint, while also offering an option for pre-loaded spike fixation to achieve rapid stabilization without pilot holes. These workflow features are intended to facilitate implantation through a more limited exposure while preserving a true zero-profile construct, including in anatomically constrained or revision settings. This manuscript is a technique-focused report that provides operative pearls and illustrative fluoroscopy rather than new clinical outcomes. These implants sit flush with the vertebral bodies, reducing overall hardware profile and potentially minimizing soft-tissue manipulation (5,7,8). Biomechanical studies have demonstrated comparable stability/arthrodesis to traditional cage-and-plate constructs, while some clinical series suggest a lower incidence of dysphagia and improved perioperative efficiency (10,11). One retrospective study of 70 patients undergoing ACDF found that use of zero-profile device was associated with decreased prevertebral swelling (15.6 versus 20.4 mm, P<0.001) and dysphagia (2.8% versus 20%, P=0.03) (5). A meta-analysis of 30 studies with 1,062 patients found minimal postoperative transient dysphagia with stand-alone grafts relative to traditional plate/screw fixation (1–7% versus 76%, P<0.05) (12). By simplifying the construct and eliminating plate selection/placement steps, zero-profile systems offer the potential to shorten operative time and reduce perioperative surgical complications (13). Of note, this construct is particularly well-suited for revision cases, especially those involving adjacent segment disease, where prior hardware and scar tissue may make surgical exposure and hardware removal challenging (14). However, traditional screw-based zero-profile devices may still present limitations, as screw placement can be challenging depending on the patient’s anatomy and the level being treated.

This manuscript presents a step-by-step surgical technique for the SABER-C zero-profile system and highlights workflow features that differentiate it from prior stand-alone cages, including integrated fixation and locking within the implant footprint and the option for pre-loaded spike fixation to enable rapid stabilization without pilot holes. This report is intended as a technical description with operative pearls and illustrative fluoroscopy, rather than a presentation of new clinical outcomes. Accordingly, we: (I) outline the clinical indications and patient selection criteria for use of this zero-profile anterior cervical plate and interbody fusion device; (II) present a detailed step-by-step surgical technique with key technical tips and intraoperative nuances; and (III) discuss the advantages of this approach relative to traditional interbody-and-plate ACDF systems and screw-based zero-profile devices, especially in the setting of revision surgery, multi-level constructs, and fusion at hard-to-access cervical levels. We present this article in accordance with the SUPER reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-212/rc).

Preoperative preparations and requirements

Indications for ACDF using a zero-profile interbody cage are largely consistent with those of conventional techniques (15,16). Overall, ACDF remains the preferred treatment for cervical radiculopathy and/or myelopathy caused by degenerative disc disease, disc herniation, or spondylosis unresponsive to nonoperative management (17). Other suitable patient candidates include but are not limited to: patients with segmental instability, progressive neurological symptoms, or requiring deformity correction (Table 1) (18).

Table 1. Indications and special considerations for use of a zero-profile ACDF.

General indications for ACDF	Special considerations for zero-profile use
Cervical radiculopathy or myelopathy due to degenerative disc disease, disc herniation, or spondylosis refractory to conservative treatment	Beneficial in patients at higher risk for postoperative dysphagia or soft-tissue irritation, where minimizing anterior hardware prominence is advantageous
Segmental instability, kyphotic deformity, or loss of disc height requiring sagittal alignment restoration and/or neuroforaminal decompression	Useful when a streamlined implantation is desired to reduce operative time and soft-tissue manipulation
1- or 2-level pathology (C2–T1) requiring anterior decompression and fusion	1- or 2-level procedures where reduced/minimally invasive exposure and simplified fixation can improve efficiency
Adjacent segment disease above or below a prior fusion	Facilitates reoperation with less dissection through scar tissue and decreased risk of esophageal irritation
Revision surgery for pseudarthrosis, hardware failure, or recurrent stenosis	Reduced operative time, smaller incision, and limited retraction make it favorable for higher-risk or complex exposures

ACDF, anterior cervical discectomy and fusion.

The zero-profile configuration expands upon these indications, offering advantages in specific clinical situations. Most notably, since the fixation mechanism is integrated within the device, the construct sits flush with the vertebral margins (Figure 1).

Figure 1.

Sample design of novel zero-profile ACDF interbody cage with spikes/screws (figure reproduced with approval from Elevation Spine, Monterey, CA). ACDF, anterior cervical discectomy and fusion.

The zero-profile configuration avoids a separate anterior plate and reduces anterior hardware prominence, which has been implicated in postoperative dysphagia and esophageal irritation in plate-based constructs (19). Any dysphagia benefit in this setting should be interpreted as device- and technique-dependent rather than solely attributable to exposure width. From a practical standpoint, the system’s low-profile design also simplifies revision procedures. For example, in adjacent segment disease, standalone devices do not require the removal of prior plating with associated technical difficulty and patient morbidity (10). Additionally, in-line spike fixation makes graft placement much easier, particularly at anatomically constrained or hard-to-access cervical levels. Moreover, patients who may benefit most from a zero-profile construct include those requiring a shorter operative time.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

Exposure and discectomy

All procedures are performed via the standard Smith-Robinson anterior cervical approach (20). The patient is positioned supine on a radiolucent table with mild neck extension, and we typically tape the bilateral shoulders caudally to optimize fluoroscopic visualization. After confirming the appropriate level of interest via lateral X-ray fluoroscopy, a transverse skin incision is made along a natural skin crease/Langer line, centered over the target disc space. After dissection through subcutaneous tissue and the platysma, an avascular plane medial to the sternocleidomastoid and lateral to the strap muscles is developed bluntly to reach the anterior cervical spine. The longus colli muscles are elevated subperiosteally via bipolar electrocautery or with blunt dissection, and self-retaining retractors are placed to expose the target levels with or without Caspar pins placed across adjacent vertebral bodies of interest to facilitate disc space distraction.

Following exposure, standard disc preparation is performed involving annulotomy using a 15 blade and full discectomy from uncinate process to uncinate process using a combination of curettes, pituitary rongeurs, and high-speed burrs. Special care is afforded to cartilaginous endplates, to remove the disc carefully while preserving subchondral bone to minimize subsidence risk. Neural decompression is confirmed both visually, as well as tactilely with a nerve hook.

Compared with traditional plate-and-cage constructs, placement of a zero-profile ACDF plate and interbody (SABER-C, Elevation Spine, Monterey, CA) integrates fixation within the implant footprint and avoids the need for a separate anterior plate; in select cases, this may streamline the workflow by eliminating plate sizing and positioning steps. The implant is designed to sit flush with the anterior vertebral margin (Figure 2), maintaining a true zero-profile footprint while providing integrated fixation and load-bearing interbody support. This may be particularly advantageous in revision or adjacent-segment settings where prior anterior hardware can complicate access. Of note, the SABER-C system is U.S. Food and Drug Administration (FDA)-cleared as both an anterior cervical plate and an interbody fusion device (combining the blue titanium plate component with a nested titanium interbody cage). Furthermore, since the plate sits entirely flush within vertebral margins, the implant maintains a true zero-profile footprint, while providing the fixation of a plate, and the load-bearing support of an interbody. By reducing anterior hardware prominence, zero-profile constructs have been associated with lower dysphagia rates in some series; however, the literature is mixed and any dysphagia benefit should be interpreted as device- and technique-dependent rather than solely attributable to exposure width. Importantly, exposure width does not necessarily equate to retraction force; adequate visualization and safe decompression should guide the extent of exposure based on surgeon judgment and patient anatomy.

Figure 2.

Comparison of fixation corridors for a traditional plate-and-screw construct versus a zero-profile integrated fixation device. The zero-profile corridor remains within the vertebral body margins, which may reduce the need for plate sizing/positioning and can facilitate fixation when anterior working space is constrained (figure reproduced with approval from Elevation Spine, Monterey, CA).

Implant sizing and placement

After thorough decompression and endplate preparation, trial spacers are inserted under fluoroscopy to determine the optimal implant height, footprint, and lordosis restoration (Figure 3A). The selected implant should restore disc height without over distraction and should seat flush with the anterior vertebral margins. This sizing process is unchanged between spike based and screw based fixation, as both options rely on identical cage positioning and alignment. Once the correct size is confirmed, the definitive cage is mounted on the insertion handle and advanced along the disc space trajectory until the anterior margin is flush with the vertebral bodies (Figure 3B).

Figure 3.

Implant sizing and placement. (A) Trial spacer under fluoroscopy to confirm appropriate height/footprint and restore disc height without over-distraction. (B) Final implant insertion demonstrating the anterior implant margin seated flush with the vertebral bodies, a key step to optimize fixation trajectory and maintain a true zero-profile construct.

The SABER-C system incorporates self-drilling, self-tapping screws or spikes, respectively, that are able to provide immediate fixation through the anterior cervical plate. Relative to other zero-profile ACDF systems, this novel device is able to be implanted via a smaller corridor (Figure 2) and more efficiently by using pre-loaded spike fixation. Of note, spike fixation can be delivered simultaneously or individually. Regarding screw insertion both straight and angled drivers are available for screw fixation, allowing controlled screw insertion through a narrow exposure. Fixation trajectories should be confirmed via fluoroscopy to ensure adequate bony purchase (Figure 4). Additionally, while placing the graft, the two “feet” of the inserter allow the surgeon to confirm the graft is not obliquely placed.

Figure 4.

Spike fixation and final verification. (A) Deployment of self-tapping spikes through the inserter demonstrating the intended deployment trajectory into the rostral/caudal vertebral bodies without pilot holes. (B) Final AP and lateral fluoroscopy confirming symmetric seating, appropriate spike depth/trajectory, and restoration of disc height/alignment. AP, anteroposterior.

Spike technique

Once the appropriate anterior cervical plate and interbody size has been selected, spikes or screws may be utilized. When using spike fixation, the desired length of spikes are loaded into the spike carriage, which is then mounted to the end of the insertion handle, filled with bone allograft and/or autograft based on surgeon preference, and finally the device is advanced into the disc space. The fixation spikes are deployed, without the need for pilot holes, through the inserter and into the anterior cervical plate securing it to the rostral and caudal vertebra. Because spike fixation engages the vertebral bodies, careful technique is required to avoid endplate violation; preserving the subchondral bone, avoiding over-distraction, selecting an appropriate implant footprint, and confirming controlled deployment under fluoroscopy are essential to minimize the risk of endplate fracture. We recommend starting with the central spine (caudally facing spike), then using the key to engage the two lateral, cranially directed, spikes. Final fluoroscopy is used to confirm symmetric seating and appropriate osseous engagement. Additionally, an audible change in the sound generated from malleating the keys can be recognized, with experience, to indicate complete insertion of the spikes. Fluoroscopic imaging confirms optimal spike trajectory and depth. The spike-based technique is particularly advantageous in standard or revision settings or in cases with restricted access, where minimizing operative steps and avoiding additional anterior plate placement can be beneficial.

Screw technique

When using self-tapping/drilling screws, the workflow follows a similar sequence. Once the appropriate anterior cervical plate and interbody size have been selected, the device is mounted to the end of the insertion handle, filled with bone allograft and advanced into the disc space. After plate and interbody device are flush with the anterior vertebral body, the inserter can be removed. Under lateral fluoroscopy, the inferior, caudally directed, screw is placed first through the anterior cervical plate, using either a straight driver, or angled driver when access is constrained. The superior, cranially directed, screws are placed next and advanced to secure all screw heads flush within the implant. Fluoroscopic imaging confirms optimal screw trajectory and depth.

Once all spikes or screws are fully seated, the locking plate is advanced to secure the fixation heads in place, preventing backout while maintaining a true zero-profile construct. Because fixation and locking are performed entirely within the implant footprint, the system requires no additional exposure or hardware beyond the vertebral margins. It is estimated at least an extra 5−10 minutes of operative time is saved by forgoing the traditional sizing/placement of plate with associated screws. More importantly, there is no unnecessary stretching of the tissues that occurs with plate sizing and screw placement, which leads to less stretch injuries. Overall, this novel streamlined workflow allows the entire construct to be implanted through a smaller surgical corridor compared with traditional plate-and-cage systems, reducing retraction time and overall operative duration. Final anteroposterior (AP) and lateral fluoroscopic images are obtained, which confirms appropriate and safe placement of the instrumentation and restoration of the disc height.

Adjacent level considerations

Of note, adjacent level and revision considerations are similar regardless of whether spikes or screws are used. Because the SABER-C system provides interbody support with integrated fixation within the implant footprint, it can facilitate extension of a prior ACDF without removing or revising existing anterior plating, thereby avoiding plate overlap and limiting the need for hardware removal in adjacent segment disease. It’s true zero-profile footprint prevents plate overlap or anterior prominence, while the integrated, plate-free construct and streamlined implantation workflow make SABER-C particularly advantageous for adjacent segment disease, revision ACDF, two-level reconstructions, and cases where minimizing operative steps and anterior hardware prominence is desirable.

In the context of a revision ACDF secondary to adjacent segment disease, it is possible to retain prior hardware and not have to remove screws/plate as in prior ACDFs, greatly reducing operative time and patient morbidity. These features are particularly valuable in patients with prior anterior surgery or those at risk for postoperative dysphagia, allowing efficient stabilization while maintaining a low anterior profile and preserving cervical alignment.

Multi-level considerations

Recently, this novel zero-profile titanium ACDF system received FDA clearance for use in cervical interbody fusion procedures involving not just one, but two adjacent degenerated spinal levels (21,22). This expanded indication highlights the system’s versatility and the growing acceptance of zero-profile technology in multilevel anterior cervical reconstruction (Figures 5,6). Currently, in the European and Asian literature there is a large volume and significant follow-up for 3 and even 4 level stand-alone interbody grafts (23,24).

Figure 5.

Revision/adjacent-segment application. (A) Lateral and (B) AP fluoroscopy demonstrating successful implantation of a zero-profile interbody device with spike fixation in a revision ACDF setting, highlighting flush anterior seating and the ability to achieve stabilization without additional anterior plate prominence. ACDF, anterior cervical discectomy and fusion; AP, anteroposterior.

Figure 6.

Two-level construct example. (A) Lateral and (B) AP fluoroscopy demonstrating successful implantation of two zero-profile interbody devices with spike fixation for a two-level ACDF, with images illustrating alignment, flush seating, and symmetric fixation at both operated levels. ACDF, anterior cervical discectomy and fusion; AP, anteroposterior.

Postoperative considerations and tasks

Following ACDF using a zero-profile interbody construct, patients undergo routine postoperative monitoring with particular attention to airway status, dysphagia symptoms, and neurologic examination. A formal swallow assessment is obtained if clinically indicated. Most patients are mobilized on the day of surgery or noting postoperative day 1, with diet advancement as tolerated. Cervical orthosis use is applied at the surgeon’s discretion based on construct stability, bone quality, and number of levels fused. Standard wound care and activity precautions are reviewed prior to discharge. Postoperative radiographs are typically obtained to confirm implant positioning and alignment, with interval imaging performed during follow-up to assess fusion progression and hardware integrity.

Tips and pearls

There are several recommendations to be mindful when considering a zero-profile ACDF interbody system like SABER-C including but not limited to:

• ❖ Maintain true inline alignment—we recommend placement of both cage and fixation along a single, inline trajectory. Consistent midline orientation during decompression and trialing ensures proper seating and balanced screw placement without retractor adjustment.

• ❖ Seat the implant flush, not recessed—the cage should be positioned level with the anterior vertebral body. Recessing can restrict screw angulation and locking plate engagement, while proud placement increases the risk of postoperative dysphagia.

• ❖ Use self-drilling screws/spikes for immediate fixation—unlike other ACDF systems including other zero-profile systems that rely on screws for provisional stability, SABER-C employs self-drilling, self-tapping screws/spikes able to self-deploy rapidly without drilling additional holes.

• ❖ Engage the integrated locking plate—once all screws are fully seated, the internal anterior locking mechanism is advanced to secure the screw heads and maintain the true zero-profile design, preventing implant backout.

• ❖ Work through a smaller corridor—the construct allows full fixation through a limited exposure, an advantage in two-level or revision cases where retraction, scar dissection and overall operative time should be minimized.

• ❖ Use angled drivers for constrained anatomy—the available angled instruments enable controlled screw insertion when working around osteophytes or in revision settings with restricted exposure.

• ❖ Revision surgery—zero-profile ACDF cages can be used in context of revision ACDF for adjacent segment disease. Instead of plate removal and construct extension increasing operative time and decreasing screw purchase, a zero-profile ACDF can be added to cranial/caudal levels.

Discussion

When compared with traditional ACDF constructs that include plate/screws along with cage, zero-profile interbody systems represent a meaningful advancement in anterior cervical fusion techniques. As part of the surgical approach, since the fixation is contained within the implant footprint, the overall exposure needed is smaller with decreased soft-tissue dissection required. This feature is particularly advantageous in revision surgery or multilevel cases, where space is limited and prior hardware may complicate access. Intraoperatively, this integrated design simplifies the operative sequence (implant placement and screw fixation occur through a single, inline trajectory) allowing the procedure to be completed more efficiently. By eliminating a separate anterior plate, the construct sits flush with the vertebral bodies and avoids anterior prominence that can contribute to postoperative dysphagia, esophageal irritation, or having a mis-sized plate contributing to adjacent segment degeneration. Despite its compact profile, the system provides secure fixation through self-drilling screws/spikes and a robust locking mechanism, achieving stability comparable to conventional plating (Table 2).

Table 2. Differences between zero-profile ACDF interbody systems and conventional plate-and-cage constructs.

Feature	Zero-profile integrated system (e.g., SABER-C)	Conventional plate-and-cage construct
Surgical exposure	Requires smaller exposure and less retraction due to inline implant and fixation; advantageous in two-level or revision cases	Wider exposure needed to accommodate separate plate and screw trajectories
Fixation method	Self-drilling, self-tapping screws with an integrated internal locking plate; no external hardware	Separate anterior plate with independently placed screws
Anterior profile	True zero-profile configuration with no prominence beyond vertebral margins, reducing dysphagia risk	Plate extends anterior to the vertebral body; may contribute to esophageal irritation
Operative workflow	Single-step implantation and fixation; shorter operative time and simplified instrumentation	Multi-step process requiring cage insertion, plate contouring, and screw alignment
Revision suitability	Ideal for adjacent segment disease; avoids removal of prior plate and reduces soft-tissue dissection	Often requires plate removal and additional exposure in revision settings
Soft-tissue impact	Reduced retraction and smaller corridor decrease esophageal manipulation and postoperative discomfort	Greater retraction and hardware prominence increase soft-tissue irritation risk

ACDF, anterior cervical discectomy and fusion.

Although multiple studies have demonstrated reduced rates of postoperative dysphagia with zero-profile constructs, the existing literature is not uniform. A prospective randomized trial comparing two-level ACDF with a zero-profile spacer versus a cage-and-plate construct did not demonstrate a statistically significant difference in dysphagia at 24-month follow-up, despite a trend favoring the zero-profile group (25). In addition, meta-analytic data have shown that certain zero-profile devices are associated with a higher rate of implant subsidence compared with plate-cage constructs, even when clinical outcomes and fusion rates are similar (26). These findings underscore that the clinical performance of zero-profile constructs is device-specific and technique-dependent, and that proposed advantages may not uniformly translate across all systems or patient populations.

Limitations

Despite the potential advantages of a zero-profile construct and a streamlined implantation workflow, several limitations warrant consideration. Integrated fixation may offer less flexibility in screw or spike trajectory in cases of severe endplate sclerosis, segmental kyphosis, or distorted anatomy, which may limit optimal implant positioning in select patients. In addition, osteoporotic bone may pose challenges for achieving secure fixation with either spikes or screws, potentially increasing the risk of subsidence or loss of fixation. Finally, while implantation through a limited surgical corridor may reduce the overall exposure width, restricted visualization in very narrow corridors can increase technical difficulty and may necessitate wider exposure at the surgeon’s discretion to ensure safe decompression and accurate implant placement. As a surgical technique report, this manuscript does not provide long-term comparative data on subsidence or fusion outcomes with this system. Future studies are warranted to evaluate these endpoints.

Conclusions

This surgical technique paper describes the use of the SABER-C zero-profile interbody fusion system for one and two-level ACDF. The technique emphasizes a streamlined operative workflow using integrated fixation and locking performed entirely within the implant footprint, with the option for pre-loaded spike fixation to achieve rapid stabilization without pilot holes. Compared with prior zero-profile constructs, SABER-C’s distinguishing features include its pre-loaded spike or screw fixation options and internal locking mechanism, which may simplify implantation through a limited surgical corridor, particularly in anatomically constrained cases and in revision or adjacent-segment settings. Importantly, this report is intended to define operative technique, technical pearls, and intraoperative considerations rather than to present new clinical outcome data. While the described workflow may offer theoretical advantages related to efficiency and reduced anterior hardware prominence, these potential benefits remain inferential. Future comparative studies are warranted to evaluate clinical outcomes such as dysphagia, implant subsidence, fusion rates, and performance in osteoporotic or deformity-related pathology.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.