Impact of early versus delayed surgery on 30-day outcomes in traumatic cervical spinal cord injury: a single-center propensity score–matched cohort study

BACKGROUND: Early surgical decompression for traumatic cervical spinal cord injury has been associated with improved neurological outcomes, but because of heterogeneity across studies there is debate about the optimal timing. Multicenter investigations perhaps offer broad generalizability, but they may lack uniform perioperative management. In this single-center retrospective cohort study, we evaluated the association between surgical timing (within or beyond 24 h) and short-term outcomes under a standardized institutional protocol. METHODS: This study was conducted at a tertiary emergency and critical care center in Japan using a cohort of patients from between 2011 and 2024. Among 512 patients with traumatic cervical spinal cord injury, 337 underwent surgical decompression and/or stabilization and they were included in the analysis. Patients were categorized into early (< 24 h) and delayed (≥ 24 h) surgery groups. Propensity score matching was applied (1:1 nearest neighbor, caliper 0.1) using sex, age, BMI, ASA class, ASIA grade, injury level, injury severity score, cervical dislocation, and procedure type. The primary outcome was neurological improvement at 30 days (≥ 1 ASIA grade). Secondary outcomes were overall complications and respiratory complications within 30 days. Logistic regression analyses were used to identify factors associated with the outcomes. RESULTS: Before matching, early surgery was associated with younger age, lower injury severity scores, and more severe neurological impairment. After propensity score matching, 100 matched pairs achieved covariate balance (standardized mean differences < 0.1-0.2). Early surgery was associated with greater neurological improvement (36.0% vs. 23.0%, p = 0.044) and fewer overall complications (31.0% vs. 57.0%, p < 0.001). Respiratory complications showed a trend toward reduction (19.0% vs. 29.0%, p = 0.098). In multivariate analyses, early surgery was independently associated with neurological improvement (OR 2.39, 95% CI 1.19-4.81, p = 0.014) and with reduced complications (OR 0.46, 95% CI 0.21-0.99, p = 0.048). CONCLUSIONS: Early surgical intervention within 24 h after traumatic cervical spinal cord injury was independently associated with improved neurological recovery and reduced short-term complications. These findings support prioritization of early decompression in institutions where surgery within 24 h is possible. TRIAL REGISTRATION: This study was approved by the Wakayama Medical University Institutional Review Board (Approval No. 4618).