The controversy about surgical vs conservative treatment of the injured spine with cord damage is centuries old. Until the end of the Second World War the majority of patients died or lived a short miserable life. Subsequently, Guttmann, an experienced neurosurgeon, realised surgery was not beneficial and sometimes detrimental to the person with spinal cord injury. Guttman, Frankel and others demonstrated with expert conservative management of the spine and the multi-system consequences of cord damage most patients made some neurological recovery and most with incomplete cord injury recovered ambulation regardless of X-ray findings. Attention to the non-medical effects of paralysis and post discharge supervision enabled persons with SCIs to enjoy complication free, dignified, productive and even competitive lives in sport and employment. The introduction of CT, MRI and safe anaesthesia led to the beliefs that surgical realignment, stabilisation and/or decompression improved neurologic outcome, facilitated early mobilisation and completion of rehabilitation, shortened hospitalisation, facilitated management and reduced cost. However, there is no supporting evidence for these claims. This manuscript describes the rationale and outcomes of conservative management and the weakness of the arguments for surgical management.