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Objective  The optimal surgical treatment for multilevel cervical spondylotic myelopathy (MCSM) remains controversial. This study compared the outcomes of three surgical approaches for MSCM treatment, focusing on the efficacy and safety of a combined approach.    Methods  This retrospective study included 153 consecutive MCSM patients (100 men, 53 women; mean age ± standard deviation, 55.7 ± 9.4 years) undergoing operations involving ≥3 intervertebral segments. The patients were divided into three groups according to surgical approach: anterior (n = 19), posterior (n = 76), and combined (n = 58). We assessed demographic variables, perioperative parameters, and clinical outcomes ≥12 months after surgery (20.5 ± 7.6 months), including Japanese Orthopaedic Association (JOA) score, improvement, recovery rate, and complications.    Results  The anterior group had the most favorable preoperative conditions, including the highest preoperative JOA score (12.95 ± 1.86,  p  = 0.046). In contrast, the combined group had the highest occupancy ratio (48.0% ± 11.6%,  p  = 0.002). All groups showed significant neurological improvement at final follow-ups, with JOA recovery rates of 59.7%, 54.6%, and 68.9% in the anterior, posterior, and combined groups, respectively ( p  = 0.163). After multivariable adjustments, the groups did not have significantly different clinical outcomes (postoperative JOA score,  p  = 0.424; improvement,  p  = 0.424; recovery rate,  p  = 0.080). Further, subgroup analyses of patients with occupancy ratios ≥50% showed similar functional outcomes following the posterior and combined approaches. Overall complication rates did not differ significantly among the three approaches ( p  = 0.600). Occupancy ratios did not have a significant negative influence on postoperative recovery following the posterior approach.    Conclusions  If applied appropriately, all three approaches are effective for treating MCSM. All three approaches had equivalent neurological outcomes, even in subgroups with high occupancy ratios. Further investigations of surgical approaches to MCSM are needed, particularly prospective multicenter studies with long-term follow-up.

Different Approaches for Treating Multilevel Cervical Spondylotic Myelopathy: A Retrospective Study of 153 Cases from a Single Spinal Center