General Principle
Timing driven by:
Neurological status
Mechanical instability
Ongoing neural compression
Age does NOT change core indications
Early Surgery (<24 hours)
Indications:
Incomplete spinal cord injury
Progressive neurological deficit
Persistent cord / cauda equina compression
Unstable injury (translation, distraction, PLC disruption)
Goal:
Decompression + stabilisation
Prevent secondary injury
Early (24–72 hours)
Indications:
Neurologically stable but:
Unstable fracture
Progressive deformity
Polytrauma (after initial stabilisation)
Goal:
Early fixation → mobilisation + ICU care
Delayed Surgery
Indications:
No neurological deficit
Stable injury
No significant compression
Medical optimisation required
Pediatric-Specific Points
Same principles as adults BUT:
More ligamentous injuries
Higher risk of SCIWORA
MRI more important
Surgery considered if:
Instability
Progressive neuro deficit
Failure of conservative care
Quick Algorithm
Neuro deficit + compression → <24h surgery
Unstable (no neuro) → 24–72h surgery
Stable + no neuro → conservative / delayed
Pits & Pearls
Early (<24h) decompression = best evidence in incomplete SCI
Stability + neurology > fracture type
Pediatric CT may look normal → MRI changes decision
Early fixation improves mobilisation & care
Pitfalls
Delaying surgery in progressive deficit
Ignoring ligamentous instability (esp. pediatric)
Operating unstable polytrauma too early
Treating timing as “fixed hours” instead of clinical decision