BACKGROUND CONTEXT With ever-rising health care costs, the value of surgical interventions should be evaluated closely. Degenerative spondylotic cervical myelopathy (DSCM) is a debilitating condition with surgical intervention being a widely accepted form of treatment. Surgery can be performed in the form of either anterior cervical decompression and fusion (ACDF) or posterior cervical decompression and fusion (PCDF). However, the hospital resource demands of elective ACDF vs PCDF are not well studied. PURPOSE The purpose of this study is to compare elective ACDF vs PCDF for DCSM on the hospital episode of care for in terms of (1) cost, (2) length of hospital stay and (3) discharge destination. STUDY DESIGN/SETTING Retrospective case-control analysis. PATIENT SAMPLE Patients were identified using the 2019 Medicare Provider Analysis and Review (MedPAR) Limited Data Set (LDS) and Centers for Medicare and Medicaid Services (CMS) 2019 Impact File. Patients undergoing elective ACDF and PCDF surgery were included. Combined anterior and posterior cervical fusions, revision cases, thoracic extension, disc replacements, fractures, traumatic cord injuries and epidural abscess were excluded. OUTCOME MEASURES Cost, length of stay, and discharge destination. METHODS Univariate analysis of potential demographic, comorbidity, surgical, perioperative and hospital confounders was performed. Multivariate models in the form of linear regression analyses for hospital cost of care and length of stay and a binary logistic regression analysis for discharge destination were performed including surgical approach and potential confounders with p <0.05 on univariate analysis. RESULTS This study included 21,350 patients who met inclusion criteria. There were 14,126 cases of elective ACDF (66.2%) and 7,224 elective PCDF (33.8%) cases. There were 10,859 males (50.9%) and 10,491 females (49.1%). The majority of patients were age 65-74 (n=11,155, p=52.2%). The mean cost of elective cervical fusion for myelopathy was $23,663.330±13,810.527 and mean length of stay was 2.86±3.01 days. The majority of patients were discharged home (78.5%). On univariate analysis, elective ACDF was associated with decreased cost ($20,991.692±11,872.223 vs. $28,887.522±15,771.514, p <0.001), length of stay (2.32±2.76 vs. 3.90±3.20 days, p 0.001), and lower incidence of non-home discharge (13.9% vs. 36.3%, p < 0.001) compared to elective PCDF. On multivariate analysis, ACDF was independently associated with decreased cost of $5,613.255 (95% confidence interval [CI]: $4,211.709-7,014.800, p <0.001), shorter length of stay by 1.145 days (95% CI:0.776-1.514 days, p <0.001), and nonhome discharge destination by 65.7% (adjusted odds ratio: 0.343, 95% CI: 0.276-0.425). CONCLUSIONS Elective primary ACDF for DCSM was independently associated with decreased cost of $5,613 (24% lower from mean cost), decreased hospital length of stay of 1.145 days, and 65.7% lower rate of nonhome discharge compared to PCDF. These findings may inform value-based care of DCSM. Patient-specific anatomic and clinical factors should always be considered in surgical decision-making for treatment of DCSM. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. With ever-rising health care costs, the value of surgical interventions should be evaluated closely. Degenerative spondylotic cervical myelopathy (DSCM) is a debilitating condition with surgical intervention being a widely accepted form of treatment. Surgery can be performed in the form of either anterior cervical decompression and fusion (ACDF) or posterior cervical decompression and fusion (PCDF). However, the hospital resource demands of elective ACDF vs PCDF are not well studied. The purpose of this study is to compare elective ACDF vs PCDF for DCSM on the hospital episode of care for in terms of (1) cost, (2) length of hospital stay and (3) discharge destination. Retrospective case-control analysis. Patients were identified using the 2019 Medicare Provider Analysis and Review (MedPAR) Limited Data Set (LDS) and Centers for Medicare and Medicaid Services (CMS) 2019 Impact File. Patients undergoing elective ACDF and PCDF surgery were included. Combined anterior and posterior cervical fusions, revision cases, thoracic extension, disc replacements, fractures, traumatic cord injuries and epidural abscess were excluded. Cost, length of stay, and discharge destination. Univariate analysis of potential demographic, comorbidity, surgical, perioperative and hospital confounders was performed. Multivariate models in the form of linear regression analyses for hospital cost of care and length of stay and a binary logistic regression analysis for discharge destination were performed including surgical approach and potential confounders with p <0.05 on univariate analysis. This study included 21,350 patients who met inclusion criteria. There were 14,126 cases of elective ACDF (66.2%) and 7,224 elective PCDF (33.8%) cases. There were 10,859 males (50.9%) and 10,491 females (49.1%). The majority of patients were age 65-74 (n=11,155, p=52.2%). The mean cost of elective cervical fusion for myelopathy was $23,663.330±13,810.527 and mean length of stay was 2.86±3.01 days. The majority of patients were discharged home (78.5%). On univariate analysis, elective ACDF was associated with decreased cost ($20,991.692±11,872.223 vs. $28,887.522±15,771.514, p <0.001), length of stay (2.32±2.76 vs. 3.90±3.20 days, p 0.001), and lower incidence of non-home discharge (13.9% vs. 36.3%, p < 0.001) compared to elective PCDF. On multivariate analysis, ACDF was independently associated with decreased cost of $5,613.255 (95% confidence interval [CI]: $4,211.709-7,014.800, p <0.001), shorter length of stay by 1.145 days (95% CI:0.776-1.514 days, p <0.001), and nonhome discharge destination by 65.7% (adjusted odds ratio: 0.343, 95% CI: 0.276-0.425). Elective primary ACDF for DCSM was independently associated with decreased cost of $5,613 (24% lower from mean cost), decreased hospital length of stay of 1.145 days, and 65.7% lower rate of nonhome discharge compared to PCDF. These findings may inform value-based care of DCSM. Patient-specific anatomic and clinical factors should always be considered in surgical decision-making for treatment of DCSM.