Sixty-five patients with degenerative cervical myelopathy (DCM) were randomized to receive intra-operative methylprednisolone 1 g at the start of decompression (n = 33) or normal saline (n = 32). The primary outcomes were neurological function (mJOA score, Nurick grade) and spinal cord MRI signal (Chen grading). Secondary outcomes included mJOA and Nurick recovery rates, mJOA domain scores (upper and lower extremity motor, sensory, sphincter), correlations among clinical/MRI measures, and complications. Outcomes were assessed at 1, 3, and 24 months; MRI was assessed at 24 months. Overall, the results revealed similar clinical improvement between groups, with a small early advantage for methylprednisolone and a statistically better MRI Chen grade at 24 months for methylprednisolone. Consequently, intra-operative methylprednisolone appeared safe and possibly neuroprotective, warranting confirmation in larger multicenter trials.