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Systematic review of the literature and prospective survey study.To characterize expert opinion regarding the timing of surgery for decompression of the injured spinal cord and critically summarize the evidence for early surgical intervention for acute spinal cord injury (SCI).The optimal timing of decompressive surgery for acute SCI is controversial, resulting in considerable variability in clinical practice. Moreover, the current opinion of spine surgeons regarding the optimal timing of surgery after SCI is unknown.We undertook a systematic review of the applied preclinical and clinical published data regarding the timing of decompression following SCI. A 20-question survey was sent to orthopedic and neurosurgical spine surgeons across the world. Response frequencies were compiled for respondent demographics and preference for timing of surgical decompression in 6 distinct clinical scenarios. χ2 statistics were used to compare response frequencies based on specialty and fellowship training.A total of 971 spine surgeons responded to the survey. In almost every clinical scenario, with the exception of central cord syndrome, the majority of respondents (≥80%) preferred to decompress the spinal cord within 24 hours. A complete cervical SCI would preferably be decompressed within 6 hours by 46.2% of respondents, but 72.9% would operate within 6 hours for an incomplete SCI in an otherwise identical clinical scenario.The majority of spine surgeons prefer to decompress the acutely injured spinal cord within 24 hours. The majority of spine surgeons prefer to decompress the cervical spine for patients with complete or incomplete cervical SCI within 24 hours. Early decompression (within 24 hours) should be considered as part of the therapeutic management of any patient with SCI, particularly those with cervical SCI. Very early decompression (within 12 hours) should be considered for a patient with an incomplete cervical SCI (with the possible exception of central cord syndrome).