Spinal cord injuries (SCI) often cause life-altering sequelae and can lead to significant morbidity. As such, there has been long-standing interest in improving the interventions used in the management of affected individuals. In the acute phase, various medical and surgical approaches have been proposed and studied to reduce the tremendous impact of trauma. In addition to evaluating the efficacy of different surgical strategies, clinicians have evaluated the benefit of early surgical decompression and stabilization. In this chapter, we describe and evaluate current surgical approaches and summarize the evidence for these interventions.