Early Neurological Improvement and Ambulation Recovery After Delayed Surgery in Surgically Selected Nonambulatory Metastatic Epidural Spinal Cord Compression: A Retrospective Cohort Study

Delayed decompression for metastatic epidural spinal cord compression (MESCC) is a common real-world problem, yet short-interval recovery after patients have already remained nonambulatory for at least 48 h is poorly defined. We retrospectively evaluated 41 surgically selected patients with MRI-confirmed epidural MESCC (Bilsky grade 2–3) and preoperative nonambulatory neurological deficit (Frankel grades A–C) lasting at least 48 h. The primary outcome was early neurological improvement, defined as a gain of at least one Frankel grade by postoperative days 10–14. The secondary outcome was early ambulation recovery, defined as postoperative Frankel grade D or E at the same interval. Early neurological improvement occurred in 20/41 patients (48.8%), and early ambulation recovery occurred in 15/41 (36.6%). No patient received postoperative index-level radiotherapy before the POD10–14 neurological assessment. Recovery was most common among patients with baseline Frankel grade C. In exploratory adjusted Firth-penalized models, ECOG performance status 3–4 was associated with lower odds of both outcomes. Rapid-growth tumors, classified using a pragmatic adapted growth-category framework, were associated with lower odds of early neurological improvement. Baseline Frankel grade C favored early ambulation recovery. Higher standardized HALP showed an exploratory association with early neurological improvement but did not alter the main clinical interpretation. Meaningful early recovery was observed in a subset of surgically selected MESCC patients despite delayed surgery, although these findings do not establish equivalence to earlier surgery or isolate the effect of surgery from multimodal oncologic care.