BACKGROUND Reports of applying cervical pedicle screw (CPS) system in the posterior cervical spine surgeries are limited because of its inherent risk of neurovascular injury. The clinical results of cervical spine instability treated with CPS system were retrospectively analyzed, and the clinical efficacy and safety of this management were evaluated. METHODS Twenty-five patients with cervical spine instability undergoing posterior C3 - C7 single/double door laminoplasty and free-hand CPS fixation as well as graft fusion were investigated; of whom, 3 were due to trauma, and 22 degenerative cervical pathogenesis. One hundred and fifty in total, CPSs were implanted in 5 cervical segments for 1 patient, 4 for 2, 3 for 18, and 2 for 4. Japanese Orthopaedic Association (JOA) score and its improvement rate, neck disability index (NDI), segmental stability, pedicle cortex perforation rate and other complication-associated parameters were assessed. RESULTS The average follow-up was 16.6 (6 - 30) months. Compared with pre-operative values, JOA score improved by 4.10 +/- 0.84 points on average (P < 0.05) at 6 months post operation, with a mean improvement rate of 61%. While the pre-operative and 6-month post-operative NDI were 32.96 +/- 6.13 and 16.84 +/- 4.40 (P < 0.05), respectively. At 6-month post-operation and the final follow-up, fused segments were stable. Pedicle cortex perforation rate was 8.0%, with no neurovascular complications observed. CONCLUSIONS Anatomizing the pre-operative radiographic data facilitates the precise operative design prior to surgery; and CPS system is capable of offering safe and satisfying outcomes in the management of cervical spine instability.