In recent years, most spinal, radicular and mixed cervical spondylosis and even vertebral artery cervical spondylosis can be cured surgically. With the development of surgical techniques and instruments and materials, the chances of major complications (mainly paralysis) from cervical spine surgery are rare. However, there are still many patients who still have unsatisfactory postoperative results, with insignificant improvement or even aggravation of neurological function. In the current medical environment, as a physician, you should try to have a good idea of what patients have had good results and what patients have poor results. In cases where severe neurological deficits already existed before surgery, the aim of surgery is to stop or slow down the natural progression of the disease and save the remaining spinal cord function. In some cases, secondary changes in the spinal cord itself, such as ischemia and degeneration due to long-term compression, have already occurred and will not heal completely on their own as a result of anterior surgery; sometimes surgery may cause deformation and embolism of the microscopic blood vessels that originally supplied blood to the spinal cord and nerve roots, which may also result in a poor prognosis for surgery. This may also lead to a poor prognosis for the surgery. All of these problems, which cannot be avoided or solved by surgery, affect the postoperative outcome, so the expected outcome after surgery should not be overestimated. What exactly are the factors? It’s complicated. The following is to throw light on them and prompt doctors to pay attention to them in their clinical work, and also to remind the majority of patients to understand their conditions correctly. I. Preoperative factors We emphasize the triad of preoperative symptoms, signs and images, therefore, the degree of spinal cord compression on images is an important evaluation indicator for conducting surgical treatment, but the degree of spinal cord compression and the early recovery of spinal cord neurological function after surgery have not shown a significant correlation. The discrepancy between the imaging presentation and clinical presentation of patients is often seen in clinical work and literature reports. The reason for this may be that the onset of CSM is closely related to long-term repetitive neck motion. When the neck is in a certain group of flexion and extension activities, it leads to a relative reduction or enlargement of the compensatory space, resulting in light MRI manifestations with severe symptoms and heavy MRI manifestations without clinical symptoms. There is also a possibility that the compressor is small but causes spinal cord vascular compression and spinal cord dysfunction. Thus, the degree of prominence of the abnormal protrusion is not the most important factor affecting the condition and the recovery of symptoms after surgery. The best outcome of surgery is within 6 months of onset, while the postoperative improvement of patients with disease duration between 6 months and 2 years and more than 2 years decreases significantly, indicating the important role of time factor in disease prognosis. From a pathological point of view, the natural course of CSM can be divided into three stages: degeneration of the cervical discs or intervertebral joints, secondary pathological changes in the bones and soft tissues of the cervical spine, and chronic compressive pathological changes in the spinal cord and its blood vessels. Many scholars have concluded that, in addition to the direct compression of the spinal cord by bone or fibrous compressive materials, disorders of spinal cord blood supply are also a major factor that cannot be ignored. As the compression time increases, the blood supply to the spinal cord becomes insufficient, eventually leading to irreversible pathological changes such as necrosis and cystic degeneration. Therefore, the longer the time, the worse the surgical result. Third, spinal cord high signal Cervical medullary signal, the compressed spinal cord shows increased signal in T2WI and equal or slightly low signal in T1WI. If the spinal cord is severely compressed, the signal in T2WI is slightly reduced. The presence of intramedullary high signal on MRI is now accepted by most scholars as an indication of spinal cord damage, but whether it means a poor prognosis is still controversial. Some believe that the presence or absence of high signal before and after surgery does not correlate with the degree of spinal cord compression or surgical outcome, and that some of the high signal is reversible and some is irreversible, so it is considered unreliable to use high signal to determine prognosis, and many patients with high signal also have a better prognosis. Therefore, the appearance of intramedullary high signal in T2WI image only reflects a pathological state after a certain degree of spinal cord compression, and has a certain reference value for judging its pathological changes, spinal cord function and prognosis. To determine the prognosis and surgical outcome, we must also consider the patient’s symptoms, signs and degree of compression, duration of compression, and location of compression.