Despite intensive preventive efforts, acute spinal cord injury remains a significant public health problem. The pathophysiology of this type of injury involves both the primary, or initial, mechanical injury and secondary injury mechanisms such as ischemia, lipid peroxidation and intracellular calcium influx. Initial management includes immobilization of the injured spine, maintenance of the airway, systemic oxygen delivery and treatment of neurogenic shock. All patients with acute spinal cord injury should receive an intravenous bolus of methylprednisolone, 30 mg per kg, within eight hours of injury, followed by an infusion of 5.4 mg per kg per hour for 23 hours. Transfer to a regional acute spinal cord injury unit for definitive management should be accomplished as soon as the patient's condition is stabilized.