A systematic review and meta-analysis of randomized and observational studies compared surgical with conservative treatment for cervical spondylotic myelopathy. Although postoperative JOA scores were not uniformly different between groups, the surgical group showed greater improvement and a higher recovery rate overall. The findings suggest that surgery may provide more neurological recovery in appropriate patients, while also showing how differences in baseline severity and study design can influence conclusions. For HCPs, the paper is best used to frame rather than dictate treatment. Patients with progressive or clinically meaningful myelopathy may gain from decompression, but the magnitude of benefit depends on disease severity, duration and individual anatomy. Conservative treatment may still be reasonable for mild, stable cases under close observation. The evidence also highlights the limits of pooled observational data, especially when surgical patients begin with more severe disease. A careful neurological examination remains essential, and treatment should be based on clinical progression rather than imaging severity alone. The practical message is to combine patient phenotype, trajectory and evidence quality when discussing the timing of cervical decompression.