Surgical Timing After Spinal Cord Injury: A Narrative Review of Current Evidence and Perspectives

Traumatic spinal cord injury (SCI) causes severe neurological and functional disability with major socioeconomic impact. The primary trauma initiates ischemia, excitotoxicity, and inflammation, leading to progressive neuronal loss and glial scarring. Early surgical decompression is a key strategy to limit secondary injury and promote recovery, though optimal timing remains debated. Preclinical data consistently favor early intervention, while clinical studies define "early" variably (<8-72 hours). Evidence from multicenter trials and meta-analyses indicates that decompression within 24 hours offers nearly a threefold higher chance of ≥2-grade improvement on the ASIA Impairment Scale, along with better motor recovery, functional independence, and fewer complications. Ultra-early (<8-12 hours) decompression may provide additional benefit in select cases, but supporting data remain limited. The strongest effects are seen in cervical and incomplete injuries, with less consistent results in thoracic and polytrauma cases. Emerging adjuncts such as expansile duraplasty and intraoperative ultrasound may further optimize outcomes. The AO Spine-Praxis guidelines strongly recommend decompression within 24 hours, though global disparities in resources persist. Overall, evidence supports early-preferably within 24 hours-decompression to enhance recovery after acute SCI, with future studies needed to refine timing and standardize protocols worldwide.