Abstract Purpose To compare sagittal alignment and clinical outcomes between three-level hybrid surgery (HS) and anterior cervical discectomy and fusion (ACDF) on cervical spondylotic myelopathy (CSM) over a 5-year follow-up. Method The study included 32 patients with ACDF, 36 patients with 1 prosthesis and 2 cages (HS1 group), and 25 cases with 2 prostheses and 1 cage (HS2 group). Alignment parameters included C2–C7 cervical lordosis (CL), C2–C7 sagittal vertical axis (SVA), T1 slope (T1S), and T1S minus CL (T1SCL). Radiographic parameters were range of motion (ROM), upper and lower adjacent ROM (UROM and LROM), and operated-segment lordosis (OPCL), as well as adjacent segment degeneration (ASD). Clinical outcomes included the neck disability index (NDI) and Japanese Orthopedic Association (JOA) score. Results Three groups were well-matched in demographics. All groups gained comparable improvement on NDI and JOA (P 0.05) while T1S improved at 1 week later and final follow-up with HS2. The final change of all alignment parameters among the three groups was of no differences. ROM decreased and OPCL increased in all groups at the final follow-up (P 0.05). Conclusion Cervical alignment was comparably improved. HS and ACDF provided identified mid-term efficacy, and it was not necessary to have to use prosthesis on three-level CSM.