Traumatic spinal cord injury (SCI) carries a high burden of morbidity and mortality for affected patients. Depending on the severity of the injury, long-term motor and sensory outcomes may be especially poor. Surgical management of SCI is often pursued and may involve cord decompression via laminectomy or laminoplasty, sometimes including duraplasty as well. Other traumatic SCI management strategies currently under investigation for use in the acute setting involve pharmacologic control of mean arterial pressure and cerebrospinal fluid drainage to increase spinal cord perfusion pressure. Currently, there is controversy surrounding the optimal timing of surgical decompression for patients with traumatic SCI. Many animal and human studies suggest that early decompression, especially within the first 24 hours of injury, is associated with more favorable short- and long-term neurological outcomes after traumatic SCI. However, there is currently no class I evidence suggesting that early decompression is causally related to improved outcomes, and conclusions from the current body of research may be limited by experimental design. Furthermore, the feasibility of early intervention may be hindered in real-world clinical practice due to logistical challenges or concomitant injuries. This chapter provides a technical overview and summary of contemporary evidence regarding principles and timing of surgical management for patients with traumatic SCI.