Summary Summary: In the case of a patient who is awake and communicative the neurologic examination of the senso-motor reflexes provides quick results in order to determine whether partial or total injury of the spinal cord has occurred.With a patient who is unconscious or whose level of consciousness is impaired the spine must be immobilized to prevent potential neural injury until a spinal injury has been excluded by means of a thorough diagnostic procedure in the hospital.To exclude a spinal injury, normal X-rays have to be taken in the lateral and anteroposterior view. A CT scan is mandatory if the spine, especially the lower cervical spine, cannot be visualized by means of a normal X-ray. An acute, total injury of the spinal cord causes immediate flaccid paralysis and loss of all sensation and reflex activity (including autonomic functions) below the level of injury (spinal shock). Patients with an acute, total cervical spinal cord injury show diaphragmatic respiration, bradycardia and hypotension. Patients who are unconscious and/or show signs of respiratory insufficiency require early intubation and assisted ventilation. In the case of emergency intubation, orotracheal intubation with inline manual cervical immobilization is indicated. Cardiovascular resuscitation mainly requires the application of crystalloids and colloids; if hypotension persists, dobutamin must be added. It is debatable whether a high dose of methylprednisolone applied initially during the acute phase gives better results in relation to the spinal cord lesion. Patients who sustain acute traumatic inju-ries of the cervical spine with associated neurologic deficit may benefit from immediate surgical decompression and stabilization. Patients with a total lesion between the C4 and C6 levels will almost always show hypoventilation. All these patients need an artificial airway for a longer period and, for that reason, a tracheotomy should be performed early on. After days or weeks, the flaccid paralysis changes to spastic paraplegia due to exaggeration of the normal stretch reflexes. Muscle spasms occur and autonomic reflexes return. With the return of the spinal reflexes, precautions must be taken to prevent autonomic dysreflexia, a syndrome characterized by paroxysmal hypertension, bradycardia, sweating, facial flushing and headache. In severe cases cerebral haemorrhage and seizures may occur, precipitated by stimuli such as defecation or bladder distension. In the case of uro-genital procedures, especially cystoscopy, a general anaesthesia with an adequate depth or, better, a spinal anaesthesia has to be performed to prevent the onset of autonomic dysreflexia. Managing patients with paraplegia requires a staff of professional health-care workers familiar with the problems of spinal cord injury. For this reason, patients with spinal cord lesion should be transferred as soon as possible to a centre specialising in this kind of injury.