Background: Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction worldwide. Surgical decompression remains the standard of care, yet postoperative recovery is highly variable. Conventional imaging, particularly T2-weighted MRI, provides anatomical detail but correlates poorly with functional outcomes. Magnetic resonance spectroscopy (MRS) provides metabolic insights into DCM, but its prognostic role in DCM has not been fully validated.

Objective: To assess the predictive value of preoperative MRS-derived metabolite ratios, alongside clinical and imaging parameters, in determining postoperative recovery in cervical myelopathy, and to develop and validate a simplified Predictive Recovery Score (PRS) for clinical prognostication.

Methodology: This prospective observational cohort study included sixty-nine consecutive patients with cervical myelopathy who underwent surgical decompression and were enrolled and followed for two years. Neurological recovery was evaluated using the modified Japanese Orthopaedic Association (mJOA) score and Hirabayashi’s recovery rate formula. Patients were stratified into good-recovery (>50%) and poor-recovery (<50%) groups. Data collected included demographics, comorbidities, stenosis grade, compression ratio, and diffusion tensor imaging (DTI) metrics. Single voxel MRS at C2 quantified metabolite ratios (NAA/Cr, Cho/NAA, Cr/ NAA, MIn/NAA). A composite PRS was formulated by weighting significant predictors (mJOA, Cho/ NAA, Cr/NAA, MIn/NAA, comorbidity, stenosis grade) and validated against recovery outcomes.

Results: Thirty-five patients achieved good recovery, while 34 had poor recovery. Comorbidities were significantly more frequent in the poor recovery group (64.7% vs. 34.3%, p = 0.012). Preoperative

mJOA scores were lower (10.91 ± 1.64 vs. 14.31 ± 1.51, p = 0.001), and grade 3 stenosis was more prevalent (82.4% vs. 48.6%, p = 0.003) in poor recovery patients. MRS revealed elevated Cho/NAA, Cr/NAA, and MIn/NAA ratios in poor recovery patients, all inversely correlated with recovery rate. ROC analysis demonstrated good discriminative power (Cho/NAA AUC = 0.759, Cr/NAA AUC = 0.750, MIn/NAA AUC

= 0.686). Validation of the PRS showed sensitivity of 83%, specificity of 91%, and AUC of 0.92, with an optimal cutoff of 36.

Conclusion: MRS-derived metabolite ratios, particularly Cho/NAA, Cr/NAA, and MIn/NAA, are robust predictors of postoperative recovery in DCM. The PRS, validated at a threshold score of 36, demonstrated excellent discriminative accuracy in stratifying recovery potential.