Background <p>This study aimed to investigate the clinical characteristics, treatment strategies, and outcomes of patients with cervico-thoracic junction degenerative myelopathy.</p> Methods <p>A multicenter retrospective study was conducted, involving 51 adult patients with spondylotic myelopathy crossing the cervico-thoracic junction. Data on demographics, comorbidities, surgical procedures, complications, and short-term outcomes were collected. Univariate and multivariate logistic regression models were used to assess associations with postoperative outcomes, ensuring statistical rigor (e.g., multicollinearity and event-per-variable thresholds). T1-slope values were measured before and after surgery. A change within ± 2° was defined as “stable”.</p> Results <p>Patients underwent anterior-only (<i>n</i> = 13), posterior-only (<i>n</i> = 25), or combined anterior-posterior (<i>n</i> = 13) approaches. The mean preoperative T1-slope was 24.5° ± 7.6°, and the postoperative T1-slope was 28.2° ± 8.1° (<i>p</i> = 0.04). Posterior-only approaches were associated with greater early increases in T1-slope and higher complication rates. Higher ASA scores (&gt; 2) were significantly correlated with postoperative complications. Surprisingly, general comorbidities were not independently associated with worse outcomes. Multilevel myelopathy involving C7–T1 correlated with more frequent complications and T1-slope changes.</p> Conclusions <p>Surgical strategy and ASA classification emerged as key factors in short-term outcomes for CTJ myelopathy. While posterior-only approaches showed worse early radiographic and clinical results, causality cannot be inferred due to the retrospective design. Early changes in sagittal alignment (T1-slope) may reflect the quality of postoperative alignment correction, but their long-term clinical significance requires prospective evaluation. Tailored, risk-adapted surgical planning may help optimize outcomes in this complex anatomical region.</p>