TIMING OF SURGICAL DECOMPRESSION IN ACUTE TRAUMATIC SPINAL CORD INJURY: A NARRATIVE REVIEW
DOI:
https://doi.org/10.31435/ijitss.2(50).2026.5866Keywords:
Traumatic Spinal Cord Injury; Surgical Decompression; Surgical Timing; Early Surgery; ASIA Impairment Scale; Neurological RecoveryAbstract
Background. Traumatic spinal cord injury (tSCI) is a devastating condition with profound neurological, functional, and socioeconomic consequences. The secondary injury cascade — encompassing ischaemia, excitotoxicity, and oedema — provides the biological rationale for time-sensitive surgical decompression. The optimal timing of surgical decompression remains one of the most debated questions in spinal surgery, with ongoing uncertainty regarding injury-level specificity, completeness-dependent effects, and the potential benefit of ultra-early intervention.
Methods. A structured electronic search was performed in PubMed/MEDLINE and the Cochrane Library for studies published between January 2005 and May 2026. Adult patients (≥18 years) with acute blunt-mechanism tSCI at any spinal level were eligible. Included study designs comprised RCTs, prospective and retrospective cohort studies, systematic reviews, and meta-analyses reporting defined surgical timing and at least one relevant neurological or functional outcome. A total of 63 studies were included in the narrative synthesis.
Results. Convergent evidence from prospective cohorts and meta-analyses supports a benefit of early surgical decompression (within 24 hours) on neurological recovery in cervical tSCI, with pooled motor score advantages of approximately two to four points and increased odds of ASIA Impairment Scale (AIS) grade improvement. The benefit declines continuously with each additional hour of delay. For thoracic and thoracolumbar injuries, the evidence is more limited and heterogeneous, though incomplete injuries demonstrate consistent benefit. Contrary to historical assumptions, complete cervical injuries (AIS grade A) appear to benefit most from early and ultra-early (within 8–12 hours) decompression. The principal barriers to timely surgery are systemic rather than patient-related, encompassing inter-hospital transfer delays, absence of dedicated spinal emergency protocols, and competing operative priorities in polytrauma.
Conclusions. Early surgical decompression within 24 hours is supported by the preponderance of available evidence and by current international guidelines. Ultra-early decompression within 12 hours may confer additional benefit in complete cervical injuries. Addressing systemic barriers to timely surgery represents the most immediately actionable opportunity to improve outcomes at a population level. Adequately powered randomized trials, with stratification by injury level and completeness, are required to resolve persistent uncertainties.
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