Does the timing of surgical decompression influence the neurological outcome after complete traumatic spinal cord Injury? A systematic review and Meta-Analysis.

Early decompressive surgery within 24 h after traumatic spinal cord injury (tSCI) is associated with improved outcomes, but evidence specific to complete tSCI remains limited. This study aimed to compare neurological recovery following early (≤24 h) versus late (>24 h) surgical decompression in patients with complete tSCI across all spinal levels, with subgroup analyses by injury level (cervical vs. thoracolumbar). A systematic search of MEDLINE, EMBASE, and Web of Science was conducted in accordance with PRISMA guidelines. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) and Cochrane Risk of Bias 2 (RoB 2) tool. Overall certainty of evidence was evaluated using the GRADE framework. Twelve studies involving 664 patients were included in the primary outcome analysis. Meta-analysis demonstrated that early decompression (≤24 h) significantly improved the likelihood of neurological recovery in complete tSCI: patients were 1.66 times more likely to improve by ≥ 2 AIS grades (RR 1.66, 95% CI 1.13-2.46, I2 0.00%) and 2.24 times more likely to recover by ≥ 3 AIS grades to AIS D or E (RR 2.24, 95% CI 1.08-4.63, I2 0.00%). Subgroup analysis showed significant benefits of early surgery (≤24 h) for cervical complete tSCI (RR 1.96, 95% CI 1.08-3.56, I2 0.00%) but not thoracolumbar injuries. In conclusion, early decompression within 24 h significantly improves neurological recovery in patients with complete cervical tSCI. The evidence supports early surgical intervention, with moderate certainty for recovery of ≥ 3 AIS grades.