## 1 Introduction  
Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in older adults and an important cause of disability and impaired quality of life [1]. Intramedullary stress and strain during neck motion are known contributors to axonal and myelin injury in DCM [2]. However, it is not known if intramedullary stress and strain are linked to neurological dysfunction in DCM. This critical knowledge gap has limited our understanding of the clinical relevance and potential utility of incorporating spinal cord biomechanics into clinical decision-making for DCM patients. Although the direct measurement of intramedullary stress and strain is not feasible in humans, methodsto estimate intramedullary stress and strain are expected to improve the evaluation of ongoing spinal cord damage, thereby boosting the accuracy of the diagnosis and management of DCM.  
Validated finite element models (FEMs) of the human cervical spine provide a non-invasive assessment of clinical spine biomechanics in relation to its normal biomechanical function (intrinsic-cord-related and external-range-of-motion-related load transfer), injury, degeneration, or surgery [3; 4; 5]. A FEM is a computational method used to predict the behavior of materials under external mechanical loading, simulating physiological activities [6; 7]. Advances in computational capabilities and engineering software have broadened the applications of FEMs in medicine. In spine surgery, FEMs have been used to quantify implant biomechanics, evaluate load distributions in spinal structures, and predict the biomechanical effects of surgical interventions on spinal alignment and stability under physiological conditions [8; 9; 10]. Additionally, advancements in 3D modeling have enabled the development of patient-specific anatomical models from imaging modalities like MRI and CT.  
Prior approaches to the 3D FEM of the cervical spinal cord, however, have used a generic spinal cord model with geometric and material properties from animal and cadaver spinal cord tissue [11; 12; 13; 14]. These generic models do not incorporate the specific geometries of the individual patient's cervical spine, which are well-known contributors to intramedullary stress and strain [15; 16]. While a comprehensive review of patient-specific and generic FEMs is beyond the scope of this study, prior review articles have highlighted challenges faced by previous studies in developing patient-specific models. Some of these challenges include a limited scope for studying generic responses, a lack of advanced imaging tools to obtain accurate patient-specific geometries, and in some cases, limited interdisciplinary collaboration between clinical personnel and modeling teams, which are often based in engineering disciplines [17; 18; 19; 20; 21].  
The lack of patient-specific data in these models has limited the clinical translation of biophysical modeling. Patient-specific FEMs can quantify intramedullary stress and strain for individual patients more accurately and have greater potential for clinical translation. However, no prior studies have directly linked patient-specific FEM outputs to neurological dysfunction in DCM patients. This study addresses this critical gap by utilizing patient-specific FEMs to determine the relationship between pre-surgical spinal cord biomechanics and pre-surgical neurological function in DCM. By incorporating individualized spinal cord geometries, we aim to assess how intramedullary stress and strain correlate with functional impairments and clinical severity in DCM.