Neonatal necrotizing enterocolitis (NEC) is a life-threatening acute gastrointestinal disorder in preterm infants, characterized by high morbidity and mortality. Approximately 20%-60% of infants with NEC require emergency surgical intervention due to intestinal perforation or failure of medical management, and mortality risk increases markedly when surgery follows perforation. Traditional imaging and biomarkers have limited performance in predicting surgical timing. In recent years, multimodal imaging technologies, novel biomarkers, and machine learning algorithms have shown higher predictive value than conventional tests and clinical indicators for determining surgical timing in NEC. This review summarizes recent advances in predictive methodologies for surgical decision-making in NEC.