Spinal cord injury affects a large number of young individuals with a significant cost to affected persons, families and societies both in terms of economic and non-economic costs. To date, our interventions have been limited to prevention, good initial resuscitation, modest pharmacotherapy and nursing care. This review examines the role of surgery in spinal cord injury. The pathophysiology of spinal cord injury is reviewed. The compelling animal data for early decompression is discussed as well as evidence for improved neurological outcome with early decompression in humans. Finally, the impact of early surgery on non-neurological outcome and overall complication rates is examined with the concept of "damage control" discussed with relevance to spinal cord injury. It appears that favourable outcomes are achieved with early surgery, with reduced morbidity/mortality, but definitive data is still pending.