This chapter discusses the pathophysiology and critical management of spinal cord trauma. It describes the most common and significant injuries to the spinal cord. Penetrating injuries can result in a complete or partial spinal cord transection. Following the immediate trauma, secondary injury can occur to the spinal cord within minutes to hours. The mechanisms of secondary injury to the spinal cord include hypoxia, ischemia, inflammation, edema, necrosis, electrolyte and ion disturbances, excitotoxicity and apoptosis. Early intubation is considered for all patients with cervical spinal cord injuries who demonstrate any signs of inadequate ventilation or oxygenation in order to minimize secondary spinal cord injuries. Care should be taken during the intubation of patients with cervical spine injuries to minimize any movement of the neck that may cause worsening of the injury. The use of airway adjuncts, such as video laryngoscopy or fiberoptic techniques, may be preferable to direct laryngoscopy.