Background::The optimal surgical approach for four-level cervical spondylotic myelopathy remains controversial. The purpose of this study was to compare clinical and radiological outcomes and complications between the anterior and posterior approaches for four-level cervical spondylotic myelopathy.Methods::A total of 19 patients underwent anterior decompression and fusion and 25 patients underwent posterior laminoplasty and instrumentation in this study. Perioperative information, intraoperative blood loss, clinical and radiological outcomes, and complications were recorded. Japanese Orthopedic Association (JOA) score, 36-item short form survey (SF-36) score and cervical alignment were assessed.Results::There were no significant differences in JOA scores between the anterior and posterior group preoperatively (11.6 ± 1.6 n vs. 12.1 ± 1.5), immediately postoperatively (14.4 ± 1.1 n vs. 13.8 ± 1.3), or at the last follow-up (14.6 ± 1.0 n vs. 14.2 ± 1.1) (n P > 0.05). The JOA scores significantly improved immediately postoperatively and at the last follow-up in both groups compared with their preoperative values. The recovery rate was significantly higher in the anterior group both immediately postoperatively and at the last follow-up. The SF-36 score was significantly higher in the anterior group at the last follow-up compared with the preoperative value (69.4 n vs. 61.7). Imaging revealed that there was no significant difference in the Cobb angle at C2-C7 between the two groups preoperatively (-2.0° ± 7.3° n vs. -1.4° ± 7.5°). The Cobb angle significantly improved immediately postoperatively (12.3° ± 4.2° n vs. 9.2° ± 3.6°) and at the last follow-up (12.4° ± 3.5° n vs. 9.0° ± 2.6°) in both groups compared with their preoperative values (n P = 0.00). Three patients had temporary dysphagia in the anterior group and four patients had persistent axial symptoms in the posterior group.n Conclusions::Both the anterior and posterior approaches were effective in treating four-level cervical spondylotic myelopathy in terms of neurological clinical outcomes and radiological features. However, the JOA score recovery rate and SF-36 score in the anterior group were significantly higher. Persistent axial pain could be a major concern when undertaking the posterior approach.“,”Background::The optimal surgical approach for four-level cervical spondylotic myelopathy remains controversial. The purpose of this study was to compare clinical and radiological outcomes and complications between the anterior and posterior approaches for four-level cervical spondylotic myelopathy.Methods::A total of 19 patients underwent anterior decompression and fusion and 25 patients underwent posterior laminoplasty and instrumentation in this study. Perioperative information, intraoperative blood loss, clinical and radiological outcomes, and complications were recorded. Japanese Orthopedic Association (JOA) score, 36-item short form survey (SF-36) score and cervical alignment were assessed.Results::There were no significant differences in JOA scores between the anterior and posterior group preoperatively (11.6 ± 1.6 n vs. 12.1 ± 1.5), immediately postoperatively (14.4 ± 1.1 n vs. 13.8 ± 1.3), or at the last follow-up (14.6 ± 1.0 n vs. 14.2 ± 1.1) (n P > 0.05). The JOA scores significantly improved immediately postoperatively and at the last follow-up in both groups compared with their preoperative values. The recovery rate was significantly higher in the anterior group both immediately postoperatively and at the last follow-up. The SF-36 score was significantly higher in the anterior group at the last follow-up compared with the preoperative value (69.4 n vs. 61.7). Imaging revealed that there was no significant difference in the Cobb angle at C2-C7 between the two groups preoperatively (-2.0° ± 7.3° n vs. -1.4° ± 7.5°). The Cobb angle significantly improved immediately postoperatively (12.3° ± 4.2° n vs. 9.2° ± 3.6°) and at the last follow-up (12.4° ± 3.5° n vs. 9.0° ± 2.6°) in both groups compared with their preoperative values (n P = 0.00). Three patients had temporary dysphagia in the anterior group and four patients had persistent axial symptoms in the posterior group.n Conclusions::Both the anterior and posterior approaches were effective in treating four-level cervical spondylotic myelopathy in terms of neurological clinical outcomes and radiological features. However, the JOA score recovery rate and SF-36 score in the anterior group were significantly higher. Persistent axial pain could be a major concern when undertaking the posterior approach.