The retrospective study aimed to investigate the indication for hypertrophy posterior longitudinal ligament (HPLL) removal in anterior decompression for cervical spondylotic myelopathy (CSM). A total of 138 consecutive patients with CSM were divided into 2 groups with developmental cervical stenosis (DCS) (group S) and non-DCS (group N), according to the Pavlov ratio. These 2 groups were subdivided into 2 further subgroups, according to whether HPLL was removed or preserved: group SR (49 patients) and group SP (32 patients) in group S, group NR (21 patients) and group NP (36 patients) in group N. The modified Japanese Orthopedic Association score (mJOA), the modified recovery rate (mRR), quality of life (QoL), and relevant clinical data were used for clinical and radiological evaluation. The mJOA scores improved from 7.3 +/- 2.2 to 15.0 +/- 1.8 in the SR group and from 7.9 +/- 2.3 to 14.2 +/- 1.5 in the SP group (P=.036), with postoperative QoL significantly higher in the SR group than the SP group. A reduction in the diameter of enlarged spinal canals occurred at a significantly faster rate in the SP group compared with the SR group (P=.002). Multivariate regression analyses showed removal of HPLL correlated with mJOA scores (coefficient=7.337, P=.002), mRR (%) (coefficient=9.117, P=.005), PCS (coefficient=12.129, P<.001), and MCS (coefficient=14.31, P<.001) in the S group at 24 months postoperatively, while removal of HPLL did not correlate with clinical outcomes in the N group. The HPLL should, therefore, be removed when mobility was reduced and the spinal cord remained compressed after anterior decompression procedures in the patients with DCS. However, in non-DCS patients, it remains unclear as to whether removal of HPLL provides any clinical benefit, thus, HPLL removal may not be necessary.