Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction in adults and is frequently accompanied by pain, a symptom that remains under-recognised despite its profound impact on quality of life. Conventional magnetic resonance imaging (MRI) is indispensable for identifying structural spinal cord compression; however, it is unable to detect early microstructural alterations, particularly those that may contribute to pain pathophysiology. This narrative review critically appraises the limitations of standard MRI in the diagnostic assessment of DCM and examines the expanding role of advanced imaging modalities—most notably diffusion tensor imaging (DTI)—in evaluating spinal cord integrity. DTI-derived parameters, including fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD), demonstrate sensitivity to axonal and myelin injury. For example, reductions in FA and AD have been linked to axonal disruption in sensory pathways, while elevations in RD suggest demyelination, a hallmark of neuropathic pain. Despite this potential, the widespread implementation of DTI is constrained by technical heterogeneity, limited accessibility, and the absence of standardised protocols. Future research priorities include the incorporation of pain-specific imaging endpoints, longitudinal validation across diverse cohorts, and integration with artificial intelligence frameworks to enable automated analysis and predictive modelling. Collectively, these advances hold promise for enabling earlier diagnosis, refined symptom stratification, and more personalised therapeutic strategies in DCM.