Patients with acute cervical SCI frequently develop hypotension, hypoxemia, pulmonary dysfunction, and cardiovascular instability, often despite initial stable cardiac and pulmonary function. These complications are not limited to patients with complete SCI. Lifethreatening cardiovascular instability and respiratory insufficiency may be transient and episodic and may be recurrent in the first 7 to 10 days after injury. Patients with the most severe neurological injuries appear to have the greatest risk of these life-threatening events. Class III medical evidence indicates that ICU monitoring allows the early detection of hemodynamic instability, cardiac disturbances, pulmonary dysfunction, and hypoxemia. Prompt treatment of these events in patients with acute SCI reduces cardiac-and respiratory-related morbidity and mortality. Management in an ICU or other monitored setting appears to have an impact on neurological outcome after acute cervical SCI. Retrospective studies consistently report that volume expansion and blood pressure augmentation performed under controlled circumstances in an ICU setting are linked to improved ASIA scores in patients with acute SCI compared with historical controls. Class III medical evidence suggests that the maintenance of MAP at 85 to 90mm Hg after acute SCI for a duration of 7 days is safe and may improve spinal cord perfusion and ultimately neurological outcome. © 2013 by the Congress of Neurological Surgeons.