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IntroductionThe correlation between cervical alignment and clinical outcome of total disc replacement (TDR) surgery is arguable. We believe that this conflict exists because the parameters that influence the biomechanics of the cervical spine are not well understood, specifically the effect of TDR on different cervical alignments. Methods:A validated osseo-ligamentous model from C2-C7 was used in this study. The C2-C7 Cobb angle of the base model was modified to represent: lordotic (−10°), straight (0°), and kyphotic (+10°) cervical alignment. The TDR surgery was simulated at the C5-C6 segment. The range of motion (ROM), intradiscal pressure, annular stresses, and facet loads were computed for all the models. Results:The ROM results demonstrated kyphotic alignment after TDR surgery to be the most mobile when compared to intact base model (41% higher in flexion–extension, 51% higher in lateral bending, and 27% higher in axial rotation) followed by straight and lordotic alignment, respectively. The annular stresses for the kyphotic alignment when compared to intact base model were higher at the index level (33% higher in flexion–extension and 48% higher in lateral bending) compared to other alignments. The lordotic model demonstrated higher facet contact forces at the index level (75% higher in extension than kyphotic alignment, 51% higher in lateral bending than kyphotic alignment, and 78% higher in axial rotation than kyphotic alignment) when compared among the three alignment models. Conclusion:Preoperative cervical alignment should be an integral part of surgical planning for TDR surgery as different cervical alignments may significantly alter the postsurgical outcomes.