BACKGROUND: Complex degenerative cervical spondylotic myelopathy (DCM) is characterized by a variety of complex imaging features. The surgical method for DCM remains controversial. This study aimed to examine the correlation between the imaging characteristics of DCM with varying degrees of complexity and the surgical approach and clinical outcome. METHODS: A retrospective cohort study involving retrospective data collection was performed. A total of 139 patients with DCM who underwent surgery between January 2015 and January 2018 in the Orthopedics Department of Shanxi Bethune Hospital were divided into 3 groups according to the complexity of imaging features: 18 patients in the mild group, 66 patients in the moderate group, and 55 patients in the severe group. The Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) scores were used to compare the effects of neck pain and neural function prior to surgery according to the rate of improvement as of the last follow-up. Routine X-ray films were obtained at the follow-up of 3-6 months. The necessity of computed tomography (CT) and magnetic resonance imaging (MRI) examinations was determined based on clinical findings and X-ray images. Analysis of variance (ANOVA) was used to compare groups, the least significant difference (LSD) test was used for multiple comparisons, and the Chi-square test was used to compare classification indicators (imaging manifestations, gender), with P<0.05 being statistically significant. Binary logistic regression analysis was performed to determine the primary influencing factors of the JOA recovery rate. RESULTS: In all three groups, JOA and VAS scores at the final follow-up were significantly higher than those before surgery (P<0.001). There were significant differences in the preoperative VAS and JOA scores between any two groups, as well as in the VAS and JOA scores and improvement rates at the last follow-up between the mild group and the moderate group and between the mild group and the severe group (P<0.001). Age, preoperative JOA scores, MRI intramedullary hyperintensity signal, and the degree of spinal cord compression were primarily related to the nervous system recovery rate (P<0.001). CONCLUSIONS: Age, MRI intramedullary hyperintensity signal, degree of spinal cord compression, and other variables were associated with the improvement of neural function in patients with DCM. Therefore, in addition to the JOA improvement rate or VAS score, additional factors, such as the patient's condition, the improvement in quality of life, and the patient's financial capacity, should be considered in evaluating the improvement of postoperative neck pain and neural function.