Safety and Efficacy of Therapeutic Hypothermia in Traumatic Spinal Cord Injury Management: A Systematic Review and MetaAnalysis.

Introduction: Therapeutic hypothermia as a neuroprotective strategy can reduce secondary injury after acute traumatic spinal cord injury (SCI). We conducted a systematic review and metaanalysis to evaluate the impact of systemic or local hypothermia on neurological outcomes, mortality, and Intensive Care Unit (ICU) stay of SCI patients. Methods: A systematic search in PubMed, Scopus, Web of Science, Embase, and The Cochrane Central Register of Controlled Trials (CENTRAL) with no limitation of time and language was performed. Following PRISMA 2020 guidelines, two independent reviewers screened records across four databases up to 20 September 2025. Eligibility was determined using PICOS criteria: adults with acute traumatic SCI (P), receiving any hypothermic protocol (I), compared with standard normothermic management (C), with reported functional, sensory, or survival outcomes (O), and original human clinical designs (S). Data extraction and risk-of-bias evaluation were performed independently using the Joanna Briggs Institute (JBI) checklist. Pooled relative risks (RR) or mean differences (MD) were calculated with randomeffects models using RevMan 4.5.1. Results: From 305 initial records, six human studies (156 patients) met inclusion criteria. There were three systemic hypothermia trials and one local extradural protocol, plus two supportive cohorts providing timing and assessment data, but only three studies met the minimum criteria for meta-analysis processes. Overall methodological quality of included studies was lowtomoderate and none of the studies were randomized. Intervention methods included surface, and endovascular techniques maintaining body temperature at 32-34 Celsius for 24-72 hours, initiated between 1.6 -70 hours postinjury. Pooled analyses showed decreased mortality with RR = 0.57 (95% CI: 0.05 -5.88; p = 0.6883), improvement in Association Impairment Scale (AIS) with RR = 2.96 (95% CI: 0.01- 939.31; p = 0.3098); and decrease in the ICU length of stay with MD = -1.27 (95% CI: -2.46 to -0.07; p = 0.9658) days in SCI patients receiving hypothermia. Complications included pneumonia, hypotension, and bradycardia. No hypothermiarelated deaths were reported. Early initiation (< 6 hours) was consistently linked with superior functional improvement. Conclusions: The findings of six human studies reveal that therapeutic hypothermia may be a feasible, safe, and effective intervention in acute traumatic SCI. While current evidence cannot yet demonstrate mortality benefit, the observed results were directed toward neurological improvement, especially when therapy is initiated early and systemically, supporting ongoing investigation.