To compare neurological and functional outcomes after ultra-early microdiscectomy (≤12 h) versus later surgery (12–24 h, 24–48 h, >48 h) in adults with acute lumbar disc herniation presenting with motor weakness and/or cauda equina syndrome.

We retrospectively studied 300 consecutive adults undergoing emergency microdiscectomy (2015–2025) at a tertiary center. Patients were grouped by time from presentation to surgery (≤12 h, 12–24 h, 24–48 h, >48 h). Primary outcomes were motor recovery (Medical Research Council scale) and pain improvement; secondary outcomes were complications, length of stay (LOS), recurrent emergency visits and recurrent herniation. Nonparametric tests and logistic regression were used with a prespecified significance level of p < 0.001.

Ultra-early surgery was associated with more rapid immediate motor gains, most notably in plantarflexion/dorsiflexion, and shorter LOS (≤12 h: 3.8 days; >48 h: 6.2 days). Over the ≤48 h window, long-term motor recovery did not differ among ≤12 h, 12–24 h and 24–48 h groups. Rates of complications, recurrent emergency visits and recurrent herniation did not vary by timing.

In acute presentations with neurological deficits, microdiscectomy performed within 48 h remains the key threshold for favorable outcomes. Ultra-early surgery (≤12 h) appears to accelerate early neurological recovery and reduce LOS in selected acute cases, without evidence of superior long-term motor outcomes versus other ≤48 h windows. Prospective, symptom-stratified studies are warranted.