Table 2.

Summary of the Clinical Studies on Timing of Surgical Decompression of Spinal Cord for Patients with Traumatic Spinal Cord Injury

Reference	Inclusion and exclusion criteria	Study population	Injury features	Timing of intervention	Outcome measures	Study conclusions	Level of evidence	Quality assessment
Levi et al. (1991)	Patients admitted with middle to lower cervical spine trauma during July 1985 through June 1990 who underwent anterior cervical decompression and stabilization were included.	• N (all cases) = 103 • Incomplete deficit, early surgery:  ◦ N = 35  ◦ Median age: 30.4 years  ◦ Males: 80% • Incomplete deficit, delayed surgery:  ◦ N = 18  ◦ Median age: 33 years  ◦ M: 80% • Complete deficit, early surgery:  ◦ N = 10  ◦ Median age: 24.9 years  ◦ Males: 85.7% • Complete deficit, delayed surgery:  ◦ N = 40  ◦ Median age: 27.6 years  ◦ Males: 83.3%	Level of injury:  ◦ C3: 9  ◦ C4: 11  ◦ C5: 48  ◦ C6: 25  ◦ C7: 10 Cause of SCI:  ◦ MVA: 55  ◦ Diving: 24  ◦ Fall: 15  ◦ Other: 9 Associated traumatic brain injury (GCS < 14):  ◦ Incomplete deficit group: 10%  ◦ Complete deficit group: 7.5%	• Early surgery group: ≤24 h • Delayed surgery group: >24 h	Hospital LOS, complications, respiratory care, neurological assessment using Yale motor score, and functional assessment using the modified Frankel score of Benzel and Larson	• In the incomplete deficits group (Group A) one patient in the delayed surgery group died. • There was a significant difference in the hospital LOS between the early and delayed surgery groups (38.7 vs. 45.2 days; p < 0.05). • Respiratory care was significantly more required in the early surgery group than the delayed surgery group (p < 0.05). • There were no significant differences between early and delayed surgery groups with regard to the frequency of complications (p > 0.05). • In the complete deficits group (Group B), one patient died in the early surgery group. • All patients with a deficit progressed to a higher functional grade. • Early surgery group was not significant different from delayed surgery group regarding neurological and functional recovery (no p value was reported).	4	10
Clohisy et al. (1992)	Patients with incomplete neurological deficits after thoracolumbar injury who underwent spinal canal decompression and stabilization from 1981 to 1990 were included.	• N = 20 • Mean age: 33 years (15–66 years) • Males/females: 12/8	Level of injury:  ◦ T12: 9  ◦ L1: 11 Type of SCI:  ◦ Unstable burst fracture: 14  ◦ Fracture dislocation: 6 Severity of SCI (modified Frankel scale):  ◦ A: 1  ◦ B: 2  ◦ C: 8  ◦ D: 9	• Group A: anterior decompression ≤48 h • Group B: anterior decompression >48 h	• Neurologic recovery as assessed by the modified Frankel scale and ASIA motor score. • Conus medullaris recovery based on the frequency of lack of bladder and bowel control and perianal anesthesia.	• Although four patients had neurological deterioration prior to surgery (three in Group A; one in Group B), no patients had any deterioration in neurologic function after surgery. • Group A had significant mean modified Frankel grade improvement when compared to Group B (p < 0.04). • The mean ASIA motor score improvement among patients in Group A was greater than the motor improvement among patients in Group B (p = 0.01). • While four of nine patients in Group A completely recovered from a conus medullaris syndrome, six of nine patients in Group B partially recovered (p = 0.1).	4	13
Krengel et al. (1993)	• Patients with incomplete paraplegia due to acute SCI between T2 and T11 admitted from 1985 to 1990 were included. • Patients with complete SCI or conus medullaris lesions were excluded.	• N (all cases) = 14 • N (early surgery group) = 12 • N (late surgery group) = 2 • Mean age: 35 years (14–75 years) • Males: 14	Level of injury:  ◦ T3–T7: 10  ◦ T10–T11: 4 Mean follow-up time: 20 months (12–65 months) Cause of SCI:  ◦ MVA: 6  ◦ Fall: 6  ◦ Crushing: 2 Type of injury:  ◦ Burst fracture: 4  ◦ Fracture dislocation: 12	• Early surgery group: ≤24 h • Late surgery group: >24 h	Neurologic improvement of at least one Frankel grade, and surgical complications.	• All 12 patients who underwent early surgery recovered at least one Frankel grade. • No patient showed neurological deterioration after surgery. • There were no wound infections or pseudoarthrosis. • One patient had his rod removed earlier because the hook dislodged.	4	7
Duh et al. (1994)	• Patients admitted with acute SCI from May 1985 to December 1988 were included. • Patients with spinal nerve root damage only, cauda equina lesions only, injury by gunshot, other serious comorbidity, pregnancy, use of maintenance corticosteroids for other reasons, narcotic addiction, and age <13 years were excluded.	• N = 487	Not reported in the paper. However, this information is available in the original pub-lication of the Second National Spinal Cord Injury Study (NASCIS-II) in JAMA (1990): sex, age, ethnic group, height, weight, blood pressure on admission, cause of injury, associated injuries, GCS, severity of injury and cord syndrome.	• Early surgery group ≤25 h • Intermediate surgery group: from 26 to 200 h • Late surgery group: >200 h	• Neurological improvement of at least 5 points in the NASCIS-II motor score. • NASCIS-II motor score	• The results suggest that either early surgery or late surgery may be associated with increased neurological recovery, particularly motor function, but these results were equivocal. • Logistic regression analysis adjusted for severity of SCI indicated that the timing of surgery as assessed by the three study groups was not significantly associated with neurological improvement of at least 5 points in the NASCIS-II motor scores from baseline to 6 weeks (p > 0.31), 6 months (p > 0.7), or 1 year following SCI (p > 0.67). • Early surgery group and intermediate/late surgery group (>25 h) did not differ regarding the improvement in the NASCIS-II motor score at 6 weeks (p = 0.43), at 6 months (p = 0.16), or at 1 year after SCI (p = 0.14) after adjusting for age and severity of SCI.	4	18
Botel et al. (1997)	• All patients admitted from January 1, 1993, to December 31, 1995, with SCI were included.	• N (all cases) = 255 • N (traumatic SCI) = 205 • Mean age: 39.3 years (2–82 years) • Males/females: 72%/28%	Level of SCI: • Tetraplegia: 31.4% • Paraplegia: 68.6%	Early surgery: ≤24 h	Feasibility of early operation.	• 42.2% of patients reached the hospital within the first 24 h. Of these 64.4% were admitted within the first 8 h of SCI. Of the remaining 23.6% cases from other centers, 45.2% had to undergo corrective re-operations. • 178 of 255 patients required spine surgery. Of those 178 patients, 92 (51.4%) could be stabilized within 24 h after SCI. • “The time of operation depended on the day of admission on the one hand but on the state of the patient at the other, especially regarding patients with severe polytrauma and thoracic injuries.”	4	11
Campagnolo et al. (1997)	• All patients with traumatic SCI included in the Northern New Jersey Spinal Cord Injury System Database between 1990 and 1996.	Early surgery group: • N = 37 • Mean age: 32.4 years • Males/females: 35/2 Late surgery group: • N = 27 • Mean age: 41.9 years • Males/females: 23/4	Early surgery group: • Paraplegic complete: 7 • Paraplegic incomplete: 7 • Tetraplegics complete: 12 • Tetraplegics incomplete: 11 Late surgery group: • Paraplegic complete: 8 • Paraplegic incomplete: 4 • Tetraplegics complete: 8 • Tetraplegics incomplete: 7	• Early spinal stabilization group: ≤24 h • Late spinal stabilization group: >24 h	LOS in the acute SCI care, ISS, and frequency of complications in the acute stage after SCI.	• Mean LOS in the early surgery group (37.5 days) was smaller than in the late surgery group (54.7 days; p = 0.01). • The early surgery group did not differ from the late surgery group regarding the mean ISS (17.9 vs. 21.3, respectively; p = 0.10). • Both groups did not differ regarding the frequency for need for mechanical ventilation (p = 0.66), decubitus ulcers (p = 0.33), atelectasis/pneumonia (p = 0.56), wound infections (p = 0.63), autonomic dysreflexia (p = 0.64), DVT (p = 0.64), cardiac arrest (p = 1), urinary calculus (p = 0.43), gastrointestinal hemorrhage (p = 0.43), spasticity (p = 0.43), heterotopic ossification (p = 0.56), or UTI (p = 0.99).	4	12
Vaccaro et al. (1997)	The inclusion criteria were (1) patients with SCI at C3–T1, and age from 15 to 75 years; (2) patients admitted within 48 h of SCI; (3) spinal cord compression in an imaging study. The exclusion criteria were (1) associated injuries that precluded the neurologic exami-nation or surgery; (2) pre-existing comorbidities that interfered in the neurological examination or surgery.	• N (all cases) = 62 Early surgery group: • N = 34 • Mean age: 39.79 years • Males/females: 24/10 Late surgery group: • N = 28 • Mean age: 39 years • Males/females: 22/6	Level of injury: C3–T1	• Early surgery group: ≤72 h • Late surgery group: >5 days	Hospital LOS, length of rehabilitation, improvement of AIS.	No significant differences were seen in LOS in the acute post-operative ICU, length of inpatient rehabilitation or improvement in AIS, or ASIA motor score between the early vs. late surgery groups (no p values were reported).	2b	12
McLain and Benson (1999)	• Patients admitted from January 1988 to December 1993 who underwent posterior spinal stabilization were included.	• N (all cases) = 27 • Males/females: 21/6 • N (urgent surgery group) = 14 • N (early surgery group) = 13 • Mean age (urgent surgery group): 27.5 years (16–46 years) • Mean age (early surgery group): 30 years (18–58 years)	Level of injury:  ◦ Thoracic: 9  ◦ Lumbar: 18 Etiology of injury:  ◦ MVA: 74%  ◦ Fall: 18.5%  ◦ Crushed by collapsing walls: 7.5%	• Urgent surgery group: ≤24 h • Early surgery group: from 24 to 72 h	Neurological assessment (Frankel grade improvement, frequency of patients with neurological improvement, back pain score), functional change, mortality, medical complications and frequency of return to work.	• The mean ISS was 36 for early surgery group and 42 for urgent surgery group (no p was reported). • One patient died in each group. • Urgent group showed a higher mean neural improvement (1.12 vs. 0.65) and proportion with neurological improvement (88% vs. 50%) than early group (no p was reported). • Blood loss for anterior procedures was significantly higher in the urgent group but estimated blood loss for posterior procedures was similar for both groups (no p was reported). • At 49 months follow-up time, no revisions were necessitated by the urgent spinal treatment.	4	10
Mirza et al. (1999)	• Patients included were those with acute traumatic cervical SCI, ISS < 30, indirect neurologic decompression by immediate closed reduction, and surgical management of cervical spinal injury who were admitted from March 1989 to May 1991. • Patients with severe closed head injury and an ISS ≥ 30 were excluded.	• N (all cases) = 30 • N (early surgery group) = 15 • N (late surgery group) = 15 • Age range: 14–56 years • Males/females: 26/4	Level of injury: C2–C7 Injury severity:  ◦ ISS (early surgery group): 24.8  ◦ ISS (late surgery group): 26.2 Cause of injury:  ◦ MVA: 19  ◦ Fall: 3  ◦ Diving: 5  ◦ Assault: 3 Type of spine injury:  ◦ Burst fracture: 10  ◦ Dislocation: 16  ◦ Subluxation: 2  ◦ Extension injury: 1  ◦ Herniated disc: 1	• Early surgery group: ≤72 h • Late surgery group: >72 h	Neurological assessment (ASIA motor index and Frankel grade), hospital LOS, and frequency of acute complications.	• The duration of acute LOS was longer in the late surgery group than the early surgery group (36.8 vs. 21.9 days; p = 0.04). • The post-operative motor index scores were significantly different for the two groups (p = 0.01). • The change in the motor score from preoperative assessment to post-operative assessment was significant in the early surgery group (p = 0.006) but not in the late surgery group (p = 0.14). • While early surgery group showed significant improvement in the Frankel grade after surgery (p = 0.003), there was no significant differences between preoperative and post-operative assessments using Frankel grade in the late surgery group (p = 0.3). • The number of total compli-cations was significantly greater in the late surgery group than the early surgery group (p = 0.05).	4	10
Ng et al. (1999)	• Patients with cervical (C3–T1) SCI eligible for a decompressive therapy within 8 h of injury who were admitted in one of the participating centers from October 1996 to January 1997 were included.	• N = 26 • Mean age: 30.3 years (18–68 years) • Males/females: 22/4	Cause of injury:  ◦ MVA: 58%  ◦ Fall: 15%  ◦ Sports: 6%  ◦ Assault: 4% AIS:  ◦ A: 13  ◦ B: 4  ◦ C: 2  ◦ D: 7	• Early surgery group: ≤8 h • Late surgery group: >8 h	Change in AIS, time required for imaging, and decompressive surgery.	• Decompression by traction required an average of 10.9 h. Only 6 out of the 11 were able to get the procedure within 8 h of injury. • Only two patients underwent a surgical decompressive procedure within 8 h post-injury. • After surgery 84.6% of patients remained as ASIA grade A. • 19.2% improved from grade D to E in 6 months and had an average time of decompressive treatment of 30.8 h post-injury. • One patient died of sepsis and pneumonia.	4	11
Tator et al. (1999)	• Patients with SCI or cauda equina injuries admitted from August 1994 to April 1995, within 24 h of injury were included. • Subjects with gunshot wound or without signs of compression in imaging studies were excluded.	• N = 585 • Mean age: 40 years	Level of injury:  ◦ C1–7: 64.6%  ◦ T1–11: 18.7%  ◦ T11–L2: 11%  ◦ L2–S5: 5.6% Severity of injury (AIS):  ◦ A: 42.2%  ◦ B: 9.7%  ◦ C: 22.4%  ◦ D: 25.5%	• Surgery ≤24 h • Surgery between 25 and 48 h • Surgery between 48 and 96 h • Surgery >5 days	Feasibility of early operation.	• The timing of surgery varied: less than 24 h post-injury in 23.5%, between 25 and 48 h post-injury in 15.8%, between 48 and 96 h in 19%, and more than 5 days post-injury in 41.7% of patients.	4	9
Guest et al. (2002)	• Only patients with central cord syndrome admitted between 1986 and 1996 were included.	• N = 50 • Mean age: 45 years (14–77 years) • Males/females: 31/19	Cause of injury:  ◦ MVA: 22  ◦ Fall: 19  ◦ Sports: 9 Mean follow-up time: 36 months (13–48 months).	• Early surgery group: ≤24 h • Late surgery group: >24 h	• Post-spinal injury motor function scale (PSIMFS) • ASIA motor score • Bladder function • ICU LOS	• Both groups were statistically comparable with regard to the PSIMFS (p = 0.3), mean admission ASIA motor score (p = 0.45), and mean follow-up ASIA motor score (p = 0.23).	4	9
	• Patients with a severe head injury, brachial plexus injury, peripheral nerve injury, isolated cervical root injury, or extensive upper extremity fractures were excluded.		Type of injury (X-ray): spinal stenosis (n = 18), acute disc herniation (n = 16), cervical fracture/dislocation (n = 10), and spondylotic bar (n = 6) Type of injury (MRI): spinal cord contusion (n = 34) or compression (n = 16).			• Four of 16 patients in the early surgery group had preoperative bladder dysfunction and all recovered; 15 patients had bladder dysfunction in the late surgery group (n = 34), and 11 of 15 regained bladder control. • Patients in the early surgery group showed shorter ICU LOS and hospital LOS than patients in the late surgery group (no p value was reported).
Croce et al. (2001)	• Blunt trauma patients admitted over 42 months ending on December 1999 for surgical stabilization of spine fractures were included. • Patients treated with only a halo vest and patients with penetrating spine injuries were excluded.	• N = 291 • Mean age: 34 years • Males/females: 212/79	Level of injury: • Cervical: 56% • Thoracic: 27% • Lumbar: 15% Cause of injury: • MVA: 71% • Fall: 14% • Diving: 7% • Assault: 3% Frequency of SCI: 50% Mean ISS: 24	• Early surgical fixation: ≤3 days • Late surgical fixation: >3 days	AIS, FIM, hospital LOS, ICU LOS, hospital charges, complications and mortality.	• Both groups did not differ regarding ISS, admission systolic blood pressure, 48-h transfusions, frequency of SCI, cervical and lumbar fractures, but patients in the early fixation group were younger (p = 0.01) and had higher GCS (p = 0.02), lower chest abbreviated injury score (p = 0.01), and lower frequency of thoracic fracture (p = 0.01). • Although both groups did not differ regarding the time in mechanical ventilation and mortality rates, the early fixation group showed lower ICU LOS (p = 0.001), lower hospital LOS (p = 0.001), lower frequency of pneumonia (p = 0.03), and lower total hospital charges (p = 0.003) • There was no difference between the groups regarding FIM (p > 0.05). • For patients with ISS > 25, early spine fracture fixation was associated with shorter ICU LOS and hospital LOS, a lower frequency of pneumonia and less resource utilization but a significantly increased death rate (no p values were reported).414 • In patients with ISS <25, patients in the early surgery group had fewer ventilator days (p < 0.02), shorter ICU LOS (p < 0.001) and hospital LOS (p < 0.001), and lower hospital charges (p < 0.001) than the late surgery group. • In patients with significant pulmonary injury, patients in the early surgery group had shorter ICU LOS (p < 0.003) and hospital LOS (p < 0.02), lower hospital charges (p < 0.02), and less frequency of pneumonia (p < 0.003). • The frequency of DVT was lower in the early group (p < 0.04). • There were eight deaths in the early fixation group and four in the late fixation group (p > 0.05).	4	14
Papadopoulos et al. (2002)	• Patients with acute traumatic closed cervical (C1–T1) SCI admitted from 1990 to 1997 were included. • Patients who received their definitive surgical treatment outside the institution were excluded.	• N (all cases) = 91 • Protocol group: • N = 66 • Mean age: 32 years (2–92 years) • Males: 68% • Reference group: • N = 25 • Mean age: 42 years (9–75 years) • Males: 76%	Level of injury: C2–C8, T1 Time from SCI to operative decompression (protocol group): 12.6 ± 1.3 h	• Protocol group: patients who followed the University of Michigan Acute SCI Protocol, which recommends early surgical decompression of spinal cord. • Reference group: patients not included in the above group due to contraindication to MRI, need for other emergency procedures, or admitting surgeon preference.	• Frankel grade, LOS in the ICU, mortality, general care unit and rehabilitation care unit.	• Patients treated using the protocol showed a significantly greater neurological improvement than patients in the reference group (p < 0.006). • Using a multiple regression analysis, early spinal cord decompression was significantly correlated with change in Frankel grade from admission to the latest follow-up assessment (p = 0.048). • There were no significant differences between both groups regarding in-hospital mortality (p > 0.05).	4	10
Pollard and Apple (2003)	• Patients with traumatic incomplete cervical SCI admitted within 90 days of injury who completed a full rehabilitation program were included. • Patients with confounding physical and neurologic conditions were excluded.	• N = 412	Not reported	• Early surgery group: ≤24 h • Late surgery group: >24 h	Change in motor score and sensory score, follow-up motor and sensory scores (ASIA Standards).	• Neither group significantly differed with regard to change in the ASIA motor score (p = 0.42), follow-up ASIA motor scores (p = 0.73), change in the ASIA sensory score (p = 0.49), and follow-up ASIA sensory score (p = 0.5).	4	11
Chipman et al. (2004)	• Patients with thoracolumbar spinal column injury registered at the North Memorial Medical Center from January 1994 to July 2001 were included.	Early surgery and low ISS (<15):  ◦ N = 32  ◦ Mean age: 34.3 years  ◦ Males: 84.4%  ◦ Mean ISS: 10 Late surgery and low ISS:  ◦ N = 26  ◦ Mean age; 46.2 years  ◦ Males: 65.4%  ◦ Mean ISS: 10.6 Early surgery and high ISS (≥15):  ◦ N = 37  ◦ Mean age: 29.9 years  ◦ Males: 64.9%  ◦ Mean ISS: 25.8 Late surgery and high ISS:  ◦ N = 51  ◦ Mean age: 35.7 years  ◦ Males: 66.7%  ◦ Mean ISS: 29.1	• Not reported	• Group 1: surgery before 72 h and low ISS (<15). • Group 2: surgery after 72 h and low ISS. • Group 3: surgery before 72 h and high ISS (≥15). • Group 4: surgery before 72 h and high ISS.	• Hospital LOS, LOS in the ICU, frequency of infectious complications and respiratory failure.	• Although Groups 1 and 2 were comparable with regard to ISS, Group 1 showed lower frequency of anterior fusion (p = 0.047) and younger age at the time of injury (p = 0.01). There was a trend for a higher proportion of males in Group 1 than in Group 2 (p = 0.09). • There were no significant differences between Groups 3 and 4 regarding ISS (p = 0.12), proportion of males (p = 0.86), and frequency of anterior fusion (p = 0.97). There was a trend towards a younger age in Group 3 compared to Group 4 (p = 0.08). • No differences were seen between Groups 1 and 2 with regard to the frequency of infectious complications (p = 0.44), respiratory failure (p = 0.83), and all complications (p = 0.59) and well as the LOS in the ICU (p = 0.14). • Patients in Group 2 stayed significantly longer in the hospital than patients in Group 1 (p < 0.001). • While Groups 3 and 4 did not differ regarding the frequency of infectious complications (p = 0.11) and respiratory failure (p = 0.6), patients in Group 3 showed significantly lower frequency of all complications (p = 0.03), shorter hospital LOS (p < 0.001), and shorter LOS in the ICU (p = 0.003) than patients in Group 4. • Groups 3 and 4 were statistically comparable regarding the lowest systolic blood pressure (p = 0.42), resuscitation volume in crystalloid (p = 0.68), total resuscitation volume (p = 0.91), volume of packed red blood cells (p = 0.24), volume of platelets (p = 0.26), and volume of other colloids (p = 0.64). However, Group 4 received a greater volume of fresh frozen plasma than in Group 3 (p = 0.055).	4	15
McKinley et al. (2004)	• Patients admitted within the first 24 h of injury with acute, nonpenetrating, traumatic SCI were included. • Patients with penetrating injuries were excluded from analysis because of the potential for spinal cord transection and subsequent diminished potential for neurologic recovery.	• N (all cases) = 779 • N (early surgery group) = 307 • N (late surgery group) = 296 • N (non-surgery group) = 176 • Mean age: 37.65 years • Males/females: 78.8%/21.2%	• Level and severity of injury: • Paraplegia, incomplete: 17.8% • Paraplegia, complete: 27.2% • Tetraplegia, incomplete: 32.9% • Tetraplegia, complete: 22.1% • Cause of injury: • MVC: 52.9% • Fall: 28.2% • Sports: 9.1% • Medical/surgical complication: 2.8% • Other violence: 1%; • Other cause: 5.9%	• Early surgery group (≤72 h after SCI), late surgery group (>72 h) and non-surgery group. • In addition, patients who underwent spine surgery was classified into: surgery on day of injury (Group 1): ≤24 h after SCI; surgery on day 1 (Group 1.A): <48 h after SCI; and surgery on day 2 (Group 2): from 24 to 72 h of injury.	ASIA motor index, ASIA motor index efficiency, neurological level, sensory level, motor level and AIS; frequency of medical complications; hospital LOS; hospital costs; FIM motor change and FIM motor efficiency.	• All three groups were comparable regarding the FIM motor efficiency (p = 0.38); FIM motor change from admission to follow-up (p = 0.81) and from discharge to follow-up (p = 0.99). • Patients without spinal surgeries or early spine surgery had shorter acute care and total LOS than those with later surgery (p < 0.01). There were no differences among groups regarding the LOS in rehabilitation (p = 0.31). • Patients receiving no spinal surgeries or early spine surgery had lower hospital costs in the acute care (p < 0.01) and in the rehabilitation (p = 0.055) than patients who underwent late surgery. • The ASIA motor index did not differ among the three groups from acute care admission to rehabilitation (p = 0.87), from rehabilitation admission to discharge (p = 0.42), and from discharge to follow-up (p = 0.21). • No significant differences between groups were found for changes in neurologic, motor, or sensory levels or AIS grade (p > 0.15). • Late surgery group had higher incidence of pneumonia and atelectasis in acute care (p = 0.004), but not in the rehabilitation (p = 0.62). • The frequencies of DVT, pulmonary embolism, autonomic dysreflexia, and pressure ulcers were similar among the three groups in both settings (p > 0.11). • However, the occurrence of autonomic dysreflexia at 1 year after SCI was higher in the late surgery group (p = 0.03). • The groups were comparable regarding rehospitalizations (p = 0.82) or rehospitalization days (p = 0.13).	4	18
Kerwin et al. (2005)	• Patients with spine fractures requiring surgical stabilization from January 1988 to October 2001 were included.	• N (all cases) = 299 • N (early surgery group) = 174 • N (late surgery group) = 125 • Males/females: 217/82	Level of injury:  ◦ Cervical: 150  ◦ Thoracic: 90  ◦ Lumbar: 68  ◦ Multiple levels: 9 Cause of injury:  ◦ MVA: 53%  ◦ Fall: 25%  ◦ Motorcycle crash: 7%  ◦ Pedestrian versus vehicle crash: 4%  ◦ Other cause: 11%	• Early surgery group: ≤3 days of injury • Late surgery group: >3 days	Hospital LOS, ICU LOS, time on mechanical ventilation, frequency of pneumonia, modified FIM score, and mortality.	• Both groups were comparable regarding mean age, GCS, or ISS (p > 0.05). • The mortality was higher in the early group compared to the late group (6.9% vs. 2.5%), however not statistically significant (p > 0.05). • The hospital LOS was significantly shorter (p = 0.0005) for patients with early spine fixation, but no significant difference between the two groups with regard to ICU LOS (p > 0.05), frequency of pneumonia (p > 0.05), or number of days in mechanical ventilator (p > 0.05). • Both study groups were statistically comparable with regard to feeding, motor, and independence components of the modified FIM scores (p > 0.05).	4	12
Schinkel et al. (2006)	• Patients with thoracic spine injuries with an Abbreviated Injury Scale > 2 were included.	N (all cases) = 298 Early surgery group:  ◦ N = 156  ◦ Mean age: 36.7 years  ◦ Median age: 28 years  ◦ Mean ISS: 28.5  ◦ Mean GCS: 9.7 Late surgery group:  ◦ N = 49  ◦ Mean age: 38.1 years  ◦ Median age: 34 years  ◦ Mean ISS: 30.9  ◦ Mean GCS: 9.1	• Not reported	• Group I (early surgery group): ≤72 h • Group II (late surgery group): >72 h • Group III (control group): no surgery	Mortality using Trauma Injury–Injury Severity Score (TRISS) method, LOS in the ICU, dependence on mechanical ventilation, ISS and medical complications.	• Groups II and I were statistically comparable regarding the PaO2/FiO2 ratio (Horowitz ratio) (p > 0.05), frequency of sepsis (p > 0.05), and mortality by TRISS (p > 0.05). However, the mortality rate in Group II was significantly higher than in Group I (p < 0.05). • Patients in Group I had significantly shorter ICU LOS (p = 0.001), dependence on mechanical ventilation (p = 0.02), and hospital LOS (p = 0.048) than Group II.	4	12
		Control group:  ◦ N = 93  ◦ Mean age: 31.7 years  ◦ Mean ISS: 28.4  ◦ Mean GCS: 8.4				• When Groups I and II were subdivided into three further groups: (a) ISS <26; (b) 26 < ISS < 38; (c) ISS > 38; mortality rate was higher in Group II subgroups than in Group I, (Ia vs. IIa = 3% vs. 13%; Ib vs. IIb = 5% vs. 9%; Ic vs. IIc = 10% vs. 27%).
Sapkas and Papadakis (2007)	• Patients with lower cervical spine injury (C3–C7) who were admitted from January 1987 to December 200 were included.	• N = 67 • Mean age: 36 years (16–72 years) • Males/females: 49/18	Severity of SCI:  ◦ A: 20  ◦ B: 10  ◦ C: 11  ◦ D: 17  ◦ E: 9 Causes of SCI:  ◦ MVA: 73%  ◦ Fall: 18%  ◦ Diving: 7.5%  ◦ Sports: 1.5% Type of spine injury: burst fracture (n = 29) or fracture-dislocation (n = 38)	• Early surgery group: ≤72 h • Delayed surgery group: >72 h	Frankel grade and frequency of medical complications	• Patients with preoperative Frankel grade A did not improved in neurological status. • Both groups were comparable regarding the neurological improvement among patients with incomplete SCI (p = 0.44) • Two patients with grade-A injury died within 2–4 months of surgery.	4	8
Cengiz et al. (2008)	• Patients with acute thoracolumbar SCI at T8–L2 were included. • Patients who were admitted on Monday and underwent an immediate stabilization within 8 h (early surgery), and patients who were admitted on Friday and underwent operation in 3–15 days (late surgery)	• N (all cases) = 27 • Mean age: 41.4 years (23–68 years) • Males/females = 18/9 Early surgery group:  ◦ N = 12  ◦ Mean age: 39.7 years  ◦ Males/females: 8/4 Late Surgery Group:  ◦ N = 15  ◦ Mean age: 41.4 years  ◦ Males/females: 10/5	Level of injury: T8–L2	• Early surgery group: ≤8 h • Late surgery group: 3 to 15 days	AIS, GCS, LOS, and complications.	• Both groups were comparable regarding AIS (p = 0.9), and type of fracture (p ≥ 0.05). • Postoperative AIS significantly increased from the pre-operative AIS in the early surgery group (p = 0.004) and in the late surgery group (p = 0.046), but post-operative AIS of the early surgery group was better than the late surgery group (p < 0.011). • However, 83.3% of individuals in the early surgery group showed improvement in the AIS, whereas only 26.6% in the late surgery group improved their AIS. • Early surgery group had no complications, whereas the late surgery group had three cases of lung failure and one case of sepsis. There were no deaths in both groups. • Early surgery group had significantly shorter LOS in the hospital (p < 0.001) and ICU (p = 0.005) than the late surgery group.	2b	25
Chen et al. (2009)	• Patients with traumatic cervical SCI who developed central cord syndrome were included. • Patients who had associated severe head, severe nerve, severe extremity injury, died before follow-up, lost to follow-up, or had incomplete data were excluded.	• N = 49 • Age = 55.9 years • Males/females = 40/9 • N (early surgery group) = 21 • N (late surgery group) = 28	Cause of injury:  ◦ MVA = 29  ◦ Fall = 16  ◦ Sports injury = 3  ◦ Other = 1	• Early surgery group: ≤4 days. • Late surgery group: >4 days.	ASIA motor score	Both early and late surgery groups had similar ASIA motor scores in the final follow-up (88.7 vs. 90.3, respectively).	4	16

SCI, spinal cord injury; DVT, deep venous thrombosis; UTI, urinary tract infection; ASIA, American Spinal Injury Association; AIS, ASIA impairment scale; LOS, length of stay; ISS, injury severity score; FIM, functional independence measure; ICU, intensive care unit; GCS, Glasgow coma score; MPSS, methylprednisolone; MVA, motor vehicle accident.