One hundred sixty-three patients with multilevel cervical spondylotic myelopathy were randomized to receive either ventral decompression and fusion (n=63) or dorsal surgery (laminectomy with fusion or laminoplasty, n=100). The primary outcome was the change in the SF-36 physical component summary (PCS) score at 1 year. Secondary outcomes included changes in the modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI), EuroQol-5D (EQ-5D), complication rates, work status, sagittal alignment, and healthcare resource use, assessed up to 2 years. Overall, the results revealed no significant difference in the 1-year improvement in SF-36 PCS scores between the ventral (5.9 points) and dorsal (6.2 points) groups. Complication rates were significantly higher in the ventral group. The study suggests both approaches lead to meaningful functional improvements, but ventral surgery carries a higher risk of complications.