Cervicothoracic junction as a challenging area is appropriate because anterior fixation is limited due to the sternum, posterior fixation must successfully avoid the vertebral artery and spinal cord and fixation must be strong enough to withstand the force concentration resulting from the transition from flexible to rigid. Recent findings: Prior studies have suggested that anterior–posterior treatment is necessary for three-column destabilization at the cervicothoracic junction. Recent clinical and in-vitro biomechanical studies have shown that posterior-only treatment may be adequate in the absence of a total vertebrectomy.