Sex differences in patient mortality after traumatic spinal cord injury: A systematic review and meta-analysis

Traumatic spinal cord injury (TSCI) causes high mortality and long-term disability, with profound physical, emotional, and socioeconomic impact. While males represent the majority of cases, females may have lower mortality, potentially due to neuroprotection and immune modulation. However, the impact of sex on mortality remains unclear, limiting opportunities for sex-specific management.

To evaluate the association between sex and mortality after TSCI.

PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched on June 4, 2025. Observational studies reporting sex-stratified mortality in TSCI across all ages and injury severities were included. Screening and data extraction were performed independently by multiple reviewers. Random-effects meta-analysis calculated odds ratios (OR) for mortality in females versus males, with leave-one-out sensitivity analyses. Heterogeneity was assessed using I² and prediction intervals. Study quality was evaluated using an adapted Newcastle-Ottawa Scale. PRISMA and MOOSE guidelines were followed.

Ten studies including 63,992 patients (18,788 females and 45,204 males) were analyzed, with no evidence of small study bias. Sex was not significantly associated with TSCI mortality (OR 0.86, 95% CI 0.69-1.07, p = 0.18). Sensitivity analyses and qualitative evaluation of individual studies (six of ten, adjusted analyses) indicated lower mortality in females. Substantial heterogeneity was observed (I² 79.8%).

Overall, sex was not associated with TSCI mortality. Nevertheless, individual studies and sensitivity analyses indicate lower mortality in females. These findings appear context-dependent, underscoring the need for future research to clarify when sex influences outcomes, supporting individualized risk stratification and sex-specific management.