BACKGROUND CONTEXT: Magnetic resonance imaging (MRI) is the standard imaging modality for the assessment of cervical spinal cord; however, MRI assessment of the spinal cord in cervical spondylotic myelopathy patients has not demonstrated a consistent association with neurologic function or outcome after surgical or medical intervention. Thus, there is a need for sensitive imaging biomarkers that can predict functional impairment in patients with advanced cervical spondylosis. PURPOSE: To implement diffusion tensor imaging (DTI) as an imaging biomarker for microstructural integrity and functional impairment in patients with cervical spondylosis. STUDY DESIGN: Nonrandomized, single institution study. PATIENT SAMPLE: Forty-eight cervical spondylosis patients with or without spinal cord signal change underwent DTI of the spinal cord along with functional assessment. OUTCOME MEASURES: Functional measures of neurologic function via modified Japanese Orthopedic Association (mJOA) score. METHODS: A zoomed-echoplanar imaging technique and two-dimensional spatially selective radiofrequency excitation pulse were used for DTI measurement. Fractional anisotropy (FA), mean diffusivity (MD), radial and axial diffusion (AD) coefficient, AD anisotropy, ψ, defined as AD-MD, and the standard deviation (SD) of primary eigenvector orientation were evaluated at the site of compression. RESULTS: Results suggest average FA, transverse apparent diffusion coefficient, ψ, and SD of primary eigenvector orientation at the spinal level of highest compression were linearly correlated with mJOA score. Receiver-operator characteristic analysis suggested FA and ψ could identify stenosis patients with mild-to-moderate symptoms with a relatively high sensitivity and specificity. CONCLUSIONS: The results of this study support the potential use of DTI as a biomarker for predicting functional impairment in patients with cervical spondylosis.