The delineation of cervical spondylotic myelopathy as a clinical entity has improved with the development of high-quality cross-sectional neuroradiologic imaging. The natural history of this disorder is usually slow deterioration in a stepwise fashion, with worsening symptoms of gait abnormalities, weakness, sensory changes, and often pain. The diagnosis can usually be made on the basis of findings from the history, physical examination, and plain radiographs, but confirmation by magnetic resonance imaging or computed tomography and myelography is necessary. Minimal symptoms without hard evidence of gait disturbance or pathologic reflexes warrant nonoperative treatment, but patients with demonstrable myelopathy and spinal cord compression are candidates for operative intervention. Both anterior and posterior approaches have been utilized for surgical treatment of cervical myelopathy. Anterior decompression frequently requires corpectomy at one or more levels and strut grafting with bone from the ilium or fibula. Multilevel laminectomies were initially used for posterior decompression but now are either combined with fusion or replaced by laminoplasty. Any operative technique requires proper patient selection and demands adequate decompression of the canal to effect neurologic improvement. Perioperative complications can be devastating in this group of high-risk patients with cervical spondylotic myelopathy, but careful attention to detail, meticulous technique, and experience can result in excellent outcomes.