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Objective: Increased signal intensity (ISI) on T2-weighted magnetic resonance imaging (MRI) often indicates severe compression in patients with cervical myelopathy (CM). The optimal surgical approach for CM patients with ISI on T2-weighted MRI remains unclear. This meta-analysis aims to compare the clinical outcomes between anterior and posterior approaches for the treatment of these patients. Methods: MEDLINE, EMBASE, Web of Science, and Chinese National Knowledge Infrastructure (CNKI) were searched for relevant studies through January 2019. Statistical comparisons were made when appropriate. Results: A total of 9 studies (748 participants) out of 1066 citations were included in this study. All of the selected studies were high quality, as indicated by the Newcastle–Ottawa scale and the Cochrane Collaboration tool for assessing the risk of bias. Clinical outcomes were compared between anterior and posterior approaches in 4 studies (237 participants). The preoperative Japanese Orthopedic Association (JOA) score was similar between the two groups [P = 0.98, weighted mean difference (WMD) = 0.01 (− 0.58, 0.59)]. The postoperative JOA score [P < 0.05, WMD = 0.68 (0.06, 1.30)] and recovery rates [P < 0.01, WMD = 0.12 (0.06, 0.17)] were significantly higher in the anterior group than in the posterior group. Conclusion: The anterior approach was associated with better postoperative neural function than the posterior approach in CM patients with ISI on T2-weighted MRI. [ABSTRACT FROM AUTHOR]