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STUDY DESIGN Prospective randomized study from a single center OBJECTIVE.: The purpose of this study was to compare outcomes between a zero-profile (ZP) anterior cervical discectomy and fusion (ACDF) construct to a traditional ACDF with anterior plate (ACP) in the treatment of multilevel cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA Multi-level cervical spondylotic myelopathy can be treated by a variety of techniques, most commonly with corpectomy, ACDF, posterior cervical fusion or a combination of the three. Examples in the literature of comparative effectiveness of different anterior approach types are few. METHODS A total of 104 patients with multi-level cervical spondylotic myelopathy were randomized in equal proportion between treated with ACDF and ZP or ACDF with ACP. Clinical efficacy of two groups were evaluated preoperatively and at all postoperative time points through two years postoperative by the Japanese Orthopedic Association (JOA) score and the neck disability index (NDI). Radiographic changes from baseline, including disc height and cervical lordosis, were evaluated at the same postoperative time points. Complications were assessed perioperatively and through two years postoperative. RESULTS The ZP and ACP ACDF groups demonstrated substantially equivalent JOA, NDI, disc height, and lordosis improvements from baseline, which were maintained through two years postoperative. Complications occurred in 4% of ZP and 17% of ACP patients (p = 0.052), and zero (0%) ZP and four (8%) ACP patients reported hoarseness or dysphagia. CONCLUSION Zero-profile utilized in multi-level ACDF may obtained favorable clinical outcomes and a lower postoperative complications. LEVEL OF EVIDENCE 2.