AbstractThis review is concerned with changes that have occurred during the past forty years in surgery as acute therapy for spinal cord injury. Included is a summary of experimental and clinical information upon which many of the decisions for change were based. Despite the evidence, following World War II, of improvement of mortality and morbidity with non-invasive treatment of spinal cord injuries, increased utilization of surgery has continued to the present. Reasons include a decrease in mortality and morbidity with modern surgical techniques, easier handling of the patient with an unstable spine who has early fusion, and the decrease in hospital and rehabilitation costs with earlier stabilization and earlier mobilization. (J Spinal Cord Med; 18:3–8)