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Cervical disc replacement

PDF Evidence Consent
Updated Sep 2026
Illustration: spine

Why this operation has been suggested

Cervical disc replacement means replacing a worn disc in your neck with an artificial one that keeps moving. It is an approved alternative to fusion surgery, where the disc is removed and the neck bones are joined solidly. We typically offer it for wear-and-tear disease at one or two disc levels in your neck. The main reason we may suggest it for you is that keeping the treated level moving lowers the chance of trouble developing in the discs next door. In studies, more than one in four patients needed further surgery within ten years after a fusion because of problems at a nearby level. This operation aims to ease your arm and neck pain and help you return to normal function.

Before the operation

Once surgery is planned, we give you clear instructions so the day runs smoothly. You will need to stop eating and drinking for seven hours beforehand. We ask for seven hours rather than the usual six so your operation can be brought forward if the theatre list runs early. Some medicines may need to be paused before surgery; we will tell you which ones and when. Bring a written list of everything you take, including tablets, drops and natural remedies. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to change out of. Imaging such as X-rays or an MRI scan helps us plan the operation, and we usually have these from your earlier visits. If you have other medical conditions, you may need blood tests or a review with the anaesthetist before the day.

On the day

You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, the doctor who puts you to sleep for the operation and looks after you while it is done. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed.

When it is finished, you wake up in the recovery area. Nurses watch over you there while the anaesthetic wears off. Once you are stable, you either move to a ward or go home, depending on the procedure and how your recovery is going. If you are going home the same day, the person you arranged to drive you will take you there.

What the operation involves

Cervical disc replacement is done through the front of your neck. Your surgeon makes a small cut there and moves the soft tissues aside to reach your spine. The worn disc is removed, and an artificial disc that keeps moving is placed in the space. The cut is then closed.

The aim is to take pressure off the nerves in your neck while keeping that part of your neck moving, rather than joining the bones solidly as fusion surgery does.

After the operation

You will wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Your neck may feel sore, and swallowing can feel a little odd at first; this settles. Pain relief is planned for you before you leave, and your team will explain what to take. You can usually get up and walk within a few hours, with help the first time. Your team will tell you whether you go home the same day or stay one night in hospital. Someone should stay with you for the first 24 hours after you get home. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you.

Recovery

For the first few days your neck will feel sore and stiff, and swallowing may feel a little odd. This is normal and settles as the swelling goes down. Keep taking the pain relief your team planned for you, and move around gently rather than staying still in bed.

You will not wear a brace for this operation. Your neck is free to move, and that movement is part of how the artificial disc is meant to work. Your physiotherapist will guide you through simple exercises as your recovery progresses. Walking is encouraged from early on, and you can build up your distances at your own pace. Avoid heavy lifting, and anything that jars or twists your neck, until your surgeon tells you it is safe.

As the soreness settles you will notice the feeling in your arm and neck improving. Once you can turn your head far enough to check your mirrors and blind spots, brake hard without hesitating, and are off strong pain medication, you can think about driving again. If a collar has been prescribed, ask your own surgeon about driving in it, and leave the timing to them. Returning to work depends on what your job involves; desk work usually comes back before heavier duties.

Recovery varies from person to person. Your timeline may differ from someone else's, and your surgeon and physiotherapist will guide you at each review.

What can go wrong

Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.

One reason this operation is chosen over fusion surgery is that it may lower the chance of trouble developing in the discs next door. This is not certain, and some people still need more surgery later for a worn disc at a nearby level. If new arm or neck pain returns months or years after your operation, tell us at your next review so we can check the levels above and below.

Because this operation is done through the front of your neck, the nerves to your voice box sit close to the surgical path. Some people notice a hoarse or weaker voice, or find their voice tires easily, in the early weeks. Most of these changes settle. If your voice is still not back to normal after a few weeks, bring it up at your review so we can arrange the right care.

Infection is uncommon but can happen around the wound or deeper in the neck. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness that spreads out from the cut, oozing, or fevers and shivers. You may also feel generally unwell or notice swelling in your neck that makes swallowing harder. If you see any of these signs, call the clinic the same day. If you feel feverish and unwell out of hours, go to the emergency department.

Feeling anxious before surgery is common, but it matters for your recovery. Anxiety before the operation is linked with more problems afterwards, including complications and unplanned return visits to hospital. Tell your surgeon how you are feeling so support can be arranged before the day.

Nicotine use, including vaping, raises the chance of problems after neck surgery. If you use nicotine, tell your team early so we can help you stop before the operation.

Having a further operation on your neck carries more risk than the first one. If more surgery is ever discussed with you, we will explain this carefully.

The complications table on this page lists typical rates if you want the specifics.

When to call us

Most problems show up in the first few weeks, so it helps to know what to watch for. Call us if you have a fever, or if the skin around your cut becomes more red, swollen or starts oozing. Call us if your pain suddenly gets much worse, or if new pain does not settle with your usual pain relief. Go to emergency if you have calf swelling or pain, or shortness of breath, as these can be signs of a blood clot. Go to emergency straight away if you lose feeling in your arm or hand, or find you cannot move it. If you are unsure whether a symptom is serious, call the clinic and we will help you decide what to do next.

Reviewed by AI synthesis (v2) — pending human review · 9 September 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Anatomy & Pathophysiology

Bony Anatomy

  • The bony anatomy of the spine consists of 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, 5 fused sacral vertebrae, and 4 or 5 fused coccygeal vertebrae [3].
  • The vertebral body consists of a fairly cylindrical mass of bone connected by the pedicles to the posterior arch, which consists of the lamina and spinous process [3].
  • The vertebral bodies function primarily to bear weight and transfer forces to the pelvis and hips, while the posterior elements provide protection to neural structures and function as a tension band [3].
  • The cervical spine is composed of seven vertebrae and assumes a lordotic curvature [8].
  • Each vertebra is composed of an anterior portion (vertebral body) and a posterior arch formed by the pedicle, facet, lamina, and spinous process [8].
  • The vertebral body is composed of an inner region of cancellous bone surrounded by a thin shell of cortical bone [8].
  • The cervical vertebral body is an oblong structure with a coronal diameter larger than its sagittal diameter [20].
  • Cervical endplates have a cup-in-saucer configuration, distinct from the normally flat endplates of the thoracic and lumbar vertebrae [20].
  • The posterior aspect of the cervical transverse process guides the cervical spinal nerves as they exit the spinal canal, with the spinal nerves lying posterior to the vertebral artery [20].
  • The transverse process forms a half-pipe configuration that cradles the exiting spinal nerve as it projects in an anteroinferior direction [20].

Intervertebral Disc Anatomy

  • The intervertebral disc (IVD) separates each successive vertebral body except between the atlas (C1) and the axis (C2) [8].
  • The IVD is composed of an inner nucleus pulposus (NP) and an outer ring termed the anulus fibrosus (AF) [8].
  • The nucleus pulposus serves as an osmotic pump to attract water and generate hydraulic pressure when subjected to significant loads [8].
  • The anulus fibrosus encapsulates the gelatinous nucleus pulposus and provides mechanical support to contain NP pressure and constrain intervertebral rotations [8].
  • The outer anulus fibrosus is integrated with the vertebral rim via a fibrocartilage enthesis that consists of a thin layer of calcified cartilage, or "tidemark" [8].
  • The end plate is a bilayer of cartilage and bone that separates the disk from adjacent vertebrae [8].
  • The cartilage end plate integrates with the inner anulus fibrosus to fully encapsulate the nucleus pulposus [8].
  • The end plate must be strong and thick to resist significant loads but also permeable to favor chemical transport and disk cellular vitality [8].

Ligaments and Soft Tissue

  • Each successive vertebra is connected anteriorly via the IVD and posteriorly via the facet joints [8].
  • Passive support for the spinal column is provided by the anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, facet joint capsule, interspinous ligament, and supraspinous ligaments [8].
  • The erector spinae muscle runs longitudinally on the dorsal surface of the spinal column and functions to extend the spine [8].
  • The psoas muscle runs longitudinally on the ventrolateral surface of the spinal column and serves to flex the hip or laterally bend the trunk [8].
  • The multifidus muscle connects intersegmentally to stabilize the spine by acting like a bowstring to maintain lordosis [8].

Vascular Anatomy

  • The cervical spine derives its circulation primarily from the vertebral arteries [12].
  • The vertebral arteries arise from the subclavian arteries and typically enter the transverse foramen at the C6 level [12].
  • The vertebral arteries run proximally through the transverse foramina to C1, then course posteriorly over the superior aspect of the C1 ring before entering the foramen magnum [12].
  • Segmental branches to each cervical vertebra arise from the vertebral artery and the deep cervical branch of the costocervical trunk [12].
  • There is significant variability in vertebral artery anatomy, including entry through the C7 transverse foramen or anomalous courses looping through a cervical vertebral body [12].
  • The vascular supply of the spinal cord is primarily from the medullary branches of the segmental spinal arteries [12].
  • The anterior spinal artery is responsible for supplying approximately 80% of the vascular supply to the spinal cord [12].
  • Three anterior medullary arteries typically supply the cervical region of the spinal cord [12].

Biomechanics and Alignment

  • Normal cervical alignment is approximately 15° of lordosis [7].
  • The curvatures of the spine function to keep the head balanced over the pelvis and to transmit axial forces through the spine to the pelvis [7].
  • The lordotic curvatures of the cervical and lumbar spine develop secondarily later in life to allow the growing child to develop an upright posture [7].
  • The functional spinal unit consists of two vertebrae, the disk between them, and the facet joints (and their capsules) [7].
  • The functional spinal unit serves to limit motion of the spine within the confines of protecting the neural structures contained therein [7].
  • Vertebral bodies bear 70% to 90% of the static axial load of the spine [7].
  • The facet joints support 10% to 20% of axial load in a standing, neutral alignment [7].
  • In extension, the facet joints may bear up to 30% of the axial load [7].
  • In flexion, the facet joints may be burdened with up to 50% of the anterior shear load [7].
  • As compressive forces are applied to the disk, the nucleus pulposus deforms, redistributing axial forces radially [7].
  • The radial pressure generated by the nucleus pulposus is resisted by the tensile properties of the alternating bands of fibers within the anulus fibrosus [7].

Pathophysiology of Degeneration

  • Cervical degenerative disc disease (DDD) is a pathophysiologic process that incorporates a spectrum of disease states ranging from neck pain and headache to cervical radiculopathy and/or myelopathy [30].
  • Disc degeneration does not always cause pain, but it can lead to internal disc derangement or disc herniation [30].
  • The degenerative process of the spine has been divided into three stages: dysfunction, instability, and stabilization [28].
  • The dysfunction stage of spinal degeneration is seen in individuals 15 to 45 years old and is characterized by circumferential and radial tears in the disc anulus and localized synovitis of the facet joints [28].
  • The instability stage of spinal degeneration is found in 35- to 70-year-old patients and is characterized by internal disruption of the disc, progressive disc resorption, degeneration of the facet joints with capsular laxity, subluxation, and joint erosion [28].
  • The stabilization stage of spinal degeneration is present in patients older than 60 years and is characterized by progressive development of hypertrophic bone around the disc and facet joints leading to segmental stiffening or frank ankylosis [28].
  • Disc herniation is considered a complication of disc degeneration in the dysfunction and instability stages [28].
  • Spinal stenosis from degenerative arthritis is a complication of bony overgrowth compromising neural tissue in the late instability and early stabilization stages [28].
  • Degenerative cervical myelopathy results from static compression, spinal malalignment leading to altered cord tension and vascular supply, and dynamic injury mechanisms [27].
  • The cascade of events after compression of the spinal cord in degenerative cervical myelopathy includes ischemia, destruction of the blood–spinal cord barrier, demyelination, and neuronal apoptosis [27].
  • Potential genetic factors for degenerative disc disease include those related to MMP-2 and collagen IX [27].
  • Potential genetic factors for ossification of the posterior longitudinal ligament include collagen VI and XI [27].
  • Congenital anomalies including spinal stenosis, Down syndrome, and Klippel-Feil syndrome may predispose to the development of cervical disc degeneration [27].
  • The incidence of significant abnormalities shown by imaging studies in asymptomatic matched controls is 76% [30].
  • Approximately 80% of individuals are affected by nonspecific axial pain at some time in their lives [30].

Investigations

Magnetic Resonance Imaging (MRI)

  • MRI is the standard for advanced imaging of the spine and is superior to CT in most circumstances, particularly for identifying infections, tumors, and degenerative changes within the discs [23].
  • MRI is superior to CT for imaging the disc and directly imaging neural structures [23].
  • MRI typically shows the entire region of the spine (cervical, thoracic, or lumbar) [23].
  • MRI allows for imaging of the nerve root in the foramen, which is difficult with postmyelography CT because the subarachnoid space and contrast agent do not extend fully through the foramen [23].
  • MRI evidence of disc degeneration has been reported in the cervical spine in 25% of patients younger than 40 years [23].
  • MRI evidence of disc degeneration has been reported in the cervical spine in 60% of patients 60 years and older [23].
  • The most common indication for MRI of the spine is evaluation of intervertebral disc disease [22].
  • After routine radiography, MRI is the procedure of choice for screening patients with low back or sciatic pain [22].
  • In the lumbar and thoracic spine, MRI has supplanted CT myelography because it is noninvasive and less expensive [22].
  • The combination of high soft-tissue contrast and high resolution in MRI allows ideal evaluation of the intervertebral discs, nerve roots, posterior longitudinal ligament, and intervertebral foramen [22].
  • MRI provides excellent assessment of the spinal cord [22].
  • Sagittal images provide an initial evaluation of the intervertebral discs and posterior longitudinal ligament [22].
  • A normal disc exhibits signal hyperintensity on T2-weighted images due to its high water content [22].
  • The aging process results in gradual desiccation of the disc material and loss of T2-weighted signal hyperintensity [22].
  • Disc herniations or extrusions appear as convex or polypoid masses extending posteriorly into the ventral epidural space, frequently maintaining a signal intensity similar to that of the disc of origin [22].
  • Sagittal T2-weighted or gradient-echo images create a “myelographic” effect useful for evaluating compromise of the subarachnoid space [22].
  • Sagittal T1-weighted images should be closely examined to identify narrowing of the neuroforamina [22].
  • Normal T1-weighted hyperintense perineural fat in the foramina provides excellent contrast to darker displaced disc material [22].
  • Far lateral disc herniations are best seen on selected axial images localized through disc levels [22].
  • Free disc fragments appear discontinuous with the intervertebral disc, usually of intermediate T1-weighted signal in contrast to the hypointense cerebrospinal fluid [22].
  • MRI can detect significant spinal cord compromise in the cervical and thoracic spine [22].
  • Edema within the spinal cord is readily demonstrated as hyperintensity with T2 weighting [22].
  • A bulge is defined as a circumferential, symmetric extension of the disc beyond the interspace around the endplates [22].
  • A protrusion is defined as a focal or asymmetric extension of the disc beyond the interspace, with the base against the disc of origin broader than any other dimension of the protrusion [22].
  • An extrusion is defined as a more extreme extension of the disc beyond the interspace, with the base against the disc of origin narrower than the diameter of the extruding material itself or with no connection between the material and the disc of origin [22].
  • A sequestration specifically refers to a disc fragment that has completely separated from the disc of origin [22].
  • Diffusion tensor imaging is an MRI technique based on the diffusion rate of water in tissue that has been reported to demonstrate spinal cord impairment in patients with early stage cervical spondylosis before it is visible on plain MRI scans [26].
  • Information from diffusion tensor imaging can be helpful in early identification of patients in whom operative treatment is indicated [26].

Computed Tomography (CT)

  • CT has largely supplanted plain radiographs as the initial screening study of choice due to its combination of high sensitivity and specificity [24].
  • CT of the spine should be obtained in the setting of a high-risk mechanism, in the presence of acute thoracic or lumbar pain after a trauma, when fractures have been identified on plain radiographs, and in situations where there are other reasons to suspect a spine injury such as the presence of a neurologic deficit [24].
  • A dedicated spine CT consists of 2- to 3-mm wide axial slices of the thoracic and lumbar spine, typically reformatted into sagittal and coronal images [24].
  • Compared to plain radiographs, CT allows for identification of subtler fractures that might have remained undiagnosed on plain radiographs [24].
  • CT provides additional three-dimensional detail, even for more severe and easily recognized injuries, such as the degree of canal compromise and the amount of fracture comminution [24].
  • CT is particularly useful in differentiating compression fractures from burst fractures [24].
  • CT is useful in identifying subtle yet important features of an injury such as the presence of facet widening [24].
  • CT evaluation is essential in determining the stability of thoracic and lumbar spine fractures [24].
  • The primary disadvantage of CT imaging in comparison to magnetic resonance imaging (MRI) is that it does not provide as good a visualization of the soft tissues [24].
  • CT myelography is invasive and more costly than MRI and is reserved for patients who have contraindications to MRI or who have equivocal MRI examinations [22].

Clinical Correlation and Interpretation

  • One of the difficulties with MRI is showing anatomy that is abnormal but may be asymptomatic [23].
  • MRI findings must be carefully correlated with the clinical impression [23].
  • The best way to obtain meaningful clinical information from MRI is to have a specific question before the study derived from the patient’s history and careful physical examination [23].
  • The specific question for MRI interpretation is posed using the parameters of (1) neural compression, (2) instability, and (3) deformity [23].
  • In each case, the specific location of the abnormality should be suspected before MRI and confirmed with the study [23].
  • Only abnormalities in one or a combination of the categories of neural compression, instability, and deformity are important because operative techniques can treat only these problems [23].
  • Failure to interpret an imaging study in this way, especially MRI, would inevitably lead to poor clinical choices and outcomes [23].
  • Ideally, an advanced imaging study should be used for confirmation, not reevaluation [26].

References

[3] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Spinal Anatomy > Osseous Anatomy.

[7] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Spinal Anatomy > Biomechanics.

[8] Orthopaedic Basic Science Fifth Edition Print Ebook. Biology and Mechanics of the Skeletal Extracellular Matrix > Anatomy.

[12] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Spinal Anatomy > Vascular Anatomy.

[20] Rockwood And Green S Fractures In Adults. Imaging of Cervical Spine Fractures and Dislocations > Lower Cervical Spine (C3–C7).

[22] Campbell S Operative Orthopaedics 4 Volume Set. INTERVERTEBRAL DISC DISEASE.

[23] Campbell S Operative Orthopaedics 4 Volume Set. OVERVIEW OF LUMBAR AND THORACIC DISC DEGENERATION AND HERNIATION > MAGNETIC RESONANCE IMAGING.

[24] Rockwood And Green S Fractures In Adults. Imaging of Cervical Spine Fractures and Dislocations > Computed Tomography.

[26] Campbell S Operative Orthopaedics 4 Volume Set. POSTERIOR APPROACH TO THE LUMBAR SPINE, L1 TO L5 > MAGNETIC RESONANCE IMAGING.

[27] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Cervical Degenerative Conditions > Annotated References.

[28] Campbell S Operative Orthopaedics 4 Volume Set. POSTERIOR APPROACH TO THE LUMBAR SPINE, L1 TO L5 > NATURAL HISTORY OF DISC DISEASE.

[30] Campbell S Operative Orthopaedics 4 Volume Set. POSTERIOR APPROACH TO THE LUMBAR SPINE, L1 TO L5 > OVERVIEW OF DISC DEGENERATION AND HERNIATION IN THE CERVICAL SPINE.

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Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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