The etiology of cervical spondylotic myelopathy (CSM) is a manifestation of repetitive trauma to the spinal cord, resulting in pathological motor and sensory findings. As neurological dysfunction resulting from CSM can be debilitating, and as delay in management can cause permanent injury, the proper management of cervical deformity to address CSM deserves particular attention. Operative treatment options revolve around minimizing the repetitive trauma to the cervical spinal cord. Such entails a combination of deformity correction, decompression, and spinal fixation and fusion. Although CSM is predominantly a clinical diagnosis, magnetic resonance imaging (MRI) and/or myelography with CT is necessary to determine the extent and location of spinal cord compression. Surgical decompression of the spinal cord, with or without fusion achieves stability and optimizes the opportunity to recover neurological function. Both ventral and dorsal surgical approaches, as well as a combination of both approaches, are used as common operative management options, but uncertainty regarding the determination of the optimal approach remains. This uncertainty is in large part related to the heterogeneity of the pathological process and clinical and imaging presentations. The importance of the individualization of the strategic decision-making process is emphasized.