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Study Design: Retrospective comparative study., Objective: The aim of this study was to compare cervical sagittal alignment after posterior fusion surgery with lateral mass screw (LMS) and cervical pedicle screw (CPS) fixation., Summary of Background Data: LMS fixation in the subaxial cervical spine has become the preferred method of posterior cervical fusion. Although CPS has biomechanical benefits, it also has neurovascular risks. Few studies to date have compared sagittal alignment changes after posterior cervical fusion using CPS and LMS fixation., Methods: From 2006 to 2017, 71 consecutive patients underwent posterior cervical fusion using CPS (n = 51) or LMS (n = 20) fixation. Patients who underwent fusion with both types of screws and those who planned to undergo additional anterior fusion surgery were excluded. The minimum follow-up period was 12 months. C2-C7 Cobb angle for cervical lordosis (CL), fusion segmental angle (SA), C2-C7 sagittal vertical axis (SVA), and T1 slope (T1S) were measured., Results: Immediate postoperative SA and SVA differed significantly in patients who underwent CPS and LMS fixation. SA changes were more substantial after CPS fixation, with a significant difference maintained until final follow-up. Over time, CL, SVA, and T1S tended to return to their preoperative states regardless of screw type. Two patients who underwent LMS fixation, but none who underwent CPS fixation, required unplanned or additional anterior fusion surgery for revision., Conclusion: The present study is the first radiologic comparison of LMS and CPS fixation after posterior-only fusion surgery. CPS resulted in more reliable and well-preserved SA correction, whereas CL and SVA did not differ between the two groups over time due to loss of correction.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)