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This study aimed to explore the prognostic impact that the log odds of positive lymph nodes (LODDS) has on medullary thyroid cancer (MTC) and to develop a nomogram incorporating LODDS to predict the cancer-specific survival (CSS) of MTC. Data from 1110 MTC patients after total thyroidectomy were collected from the Surveillance, Epidemiology, and End Results (SEER) database and divided into training and validation cohorts. The prognostic efficiency of N status from the American Joint Committee on Cancer (AJCC) staging system, the number of positive lymph nodes (PLNN), and LODDS were compared using the Harrell concordance index (C-index), the Akaike information criterion (AIC), and area under the receiver operating characteristic (ROC) curve (AUC). A multivariate Cox analysis was performed to determine the independent prognostic factors, and a nomogram based on LODDS was constructed. The nomogram's performance was assessed with the C-index, AUC, calibration curves, and decision curve analysis (DCA). Among the three lymph node (LN) staging systems, LODDS showed the highest accuracy in predicting CSS for MTC. In the training cohort, the C-index of the LODDS-based nomogram was 0.895. The AUCs were 0.949, 0.917, 0.925, and 0.901 for predicting 1-, 3-, 5- and 10-year CSS, respectively. The calibration plots and DCA showed the superior clinical applicability of the nomogram. These results were verified in the validation cohort. As an independent prognostic factor for MTC, LODDS demonstrated superior prognostic efficiency over N status and PLNN. This LODDS-based nomogram yielded better performance than the AJCC tumor-node-metastasis (TNM) staging system in predicting CSS after surgery for MTC.