Early Predictors of Walking Recovery in Patients after Traumatic Spinal Cord Injury: A Systematic Review and Meta-Analysis

To identify, categorize, and rank the predictors of walking recovery in patients with traumatic spinal cord injury (SCI). We prospectively registered (CRD42023443454) this review and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched PubMed, Embase, Cochrane, and Web of Science until July 2025. We assessed study eligibility, extracted data, appraised study quality using the Quality In Prognostic Studies, and evaluated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation. We meta-analyzed adjusted effect estimates within the same stratification when data from two or more studies were available; when meta-analysis was not appropriate, we presented the results qualitatively. Fifty-four studies met the inclusion criteria. Study quality levels were rated as poor (3 [5.6%] of 54 studies), fair (40 [70%]), and good (11 [20.4%]) quality. Predictor variables were classified into five categories: (1) sociodemographic factors, (2) injury-related factors, (3) magnetic resonance imaging parameters, (4) serum/cerebrospinal fluid (CSF) biomarkers, and (5) treatment-related factors. American Spinal Injury Association Impairment Scale (AIS) and neurological level of injury (NLI) were found to be the most significant predictors of walking recovery (odds ratio [OR] = 3.70; 95% confidence interval [CI]: 2.86–4.79; p = 0.001; I 2 = 2%; high certainty) and (OR = 2.81; 95% CI: 1.54–5.14; p = 0.008; I 2 = 0%; moderate certainty), respectively. Patients with diabetes were less likely to regain ambulatory ability after SCI (OR = 0.64, 95% CI: 0.42–0.98; p = 0.038; I 2 = 0.0%; moderate certainty). Other widely studied predictors, such as age and timing of surgery, showed inconsistent results across cutoffs. In conclusion, the initial severity of injury (AIS and NLI) was the strongest predictor of walking recovery, indicating that patients with less severe impairment at admission had a higher probability of walking recovery.