Study design <p>Systematic Review and Meta-Analysis</p> Objectives <p>To evaluate the effect of intradural decompression (durotomy with or without duroplasty) on neurological recovery and cerebrospinal fluid (CSF)-related complications following acute traumatic spinal cord injury (SCI).</p> Methods <p>A systematic review and meta-analysis were performed according to PRISMA guidelines. Studies evaluating intradural decompression in traumatic SCI were included, and outcomes were pooled using random-effects models.</p> Results <p>Eight observational studies were included. Intradural decompression was associated with improved motor recovery (SMD 0.82, 95% CI 0.62–1.02; <i>p</i> &lt; 0.00001), with moderate heterogeneity (I² = 59%). The pooled neurological improvement rate was approximately 82%, although substantial heterogeneity was present (I² = 77%). Subgroup analysis demonstrated a significant effect in incomplete or mixed SCI populations (SMD 1.40, 95% CI 0.05–2.75), whereas the effect in complete injuries was not statistically significant (SMD 1.21, 95% CI − 0.36–2.78). No significant increase in CSF-related complications was observed (OR 2.29, 95% CI 0.79–6.63; I² = 0%). Sensitivity analyses confirmed the robustness of the overall findings despite evidence of small-study effects.</p> Conclusions <p>Intradural decompression may improve neurological recovery following acute SCI, particularly in patients with incomplete injuries. However, the current evidence is limited to observational studies with substantial heterogeneity and risk of bias. High-quality prospective comparative studies and randomized trials are required before routine adoption can be recommended.</p>