Is time really spine? Early versus delayed surgical decompression in traumatic spinal cord injury: a systematic review and meta-analysis.

PURPOSE: To evaluate whether earlier surgical decompression is associated with improved neurological and clinical outcomes compared with delayed decompression after traumatic spinal cord injury.

METHODS

MEDLINE, Scopus, Web of Science, CINAHL, the Cochrane Library and Google Scholar were searched from inception to February 2025. Comparative studies of early versus delayed decompression in adult or predominantly adult traumatic spinal cord injury cohorts were included. Three reviewers independently screened studies, extracted data and assessed risk of bias. Random-effects meta-analyses were performed where outcomes were sufficiently comparable. The primary outcomes were improvement of at least one grade and at least two grades on the American Spinal Injury Association (ASIA) Impairment Scale.

RESULTS

Seventy-eight studies comprising 31,190 reported participants were included. Surgery within 24 h was the most common definition of early decompression, although thresholds and timing origins varied substantially. Seventeen studies contributed to the analysis of AIS improvement of at least one grade. Early decompression was associated with a greater likelihood of improvement than delayed decompression (risk ratio [RR] 1.46, 95% confidence interval [CI] 1.27-1.68; I² = 48.3%). Eleven studies contributed to the analysis of AIS improvement of at least two grades, which also favoured early decompression (RR 2.18, 95% CI 1.69-2.81; I² = 0.0%). Four studies were pooled for overall complications, with no clear difference between early and delayed decompression (RR 0.97, 95% CI 0.60-1.56; I² = 74.9%). Functional recovery, mortality, length of stay, intensive care, ventilation and cost outcomes were reported inconsistently and were synthesised narratively.

CONCLUSION

Earlier surgical decompression was associated with greater AIS-grade neurological recovery after traumatic spinal cord injury, particularly for improvement of at least two grades. However, most evidence was observational and limited by heterogeneous timing definitions, inconsistent outcome reporting and residual confounding. These findings support timely decompression when medically feasible, but do not establish that surgical timing alone determines neurological recovery.

PROSPERO REGISTRATION: CRD420251000074.