Cervical sagittal alignment changes (CSACs) influence outcomes and health-related quality-of-life. Anterior cervical discectomy and fusion (ACDF), laminectomy with fusion (LCF), and laminoplasty (LP) are common treatments for multisegmental cervical spondylotic myelopathy; however, these approaches need to be compared.Our study included 167 patients who underwent ACDF, LCF, or LP. Patients were divided into four groups according to C2-C7 Cobb angle (CL): kyphosis (CL < 0°), straight (0° ≤ CL < 10°), lordosis (10° ≤ CL < 20°), and extreme lordosis (20° ≤ CL) groups. CSACs consist of two parts. CSAC from the preoperative period to the postoperative period is surgical correction change (SCC). CSAC from the postoperative period to the final follow-up period is postoperative lordosis preserving (PLP). Outcomes were evaluated using the Japanese Orthopaedic Association score and the neck disability index.ACDF, LCF, and LP had equivalent outcomes. ACDF had greater SCC than LCF and LP. During follow-up, lordosis decreased in the ACDF and LCF groups but increased in the LP group. For straight alignment, ACDF had greater CSAC and greater SCC than the LCF and LP groups but similar PLP. For lordosis alignment, ACDF and LP had positive PLP, and LCF had negative PLP. For extreme lordosis, ACDF, LP, and LCF had negative PLP; however, cervical lordosis in the LP group was relatively stable during follow-up.ACDF, LCF, and LP have different CSAC, SCC, and PLP according to a four-type cervical sagittal alignment classification. Preoperative cervical alignment is an important consideration in deciding the type of surgical treatment in CSM.© 2023. The Author(s).