Hypotension is common after acute traumatic SCI in humans. Hypotension contributes to spinal cord ischemia after injury in animal models and can worsen the initial insult and reduce the potential for neurological recovery. Although unproven by Class I medical evidence studies, it is likely that this occurs in human SCI patients as well. Because the correction of hypotension and maintenance of homeostasis is a basic principle of ethical medical practice in the treatment of patients with traumatic neurological injuries, depriving ASCI patients of this treatment would be untenable. For this reason, Class I evidence about the effects of hypotension on outcome after acute human SCI will never be obtained. However, correction of hypotension has been shown to reduce morbidity and mortality after acute human traumatic brain injury and is a guideline level recommendation for the management of traumatic brain injury. Although a similar treatment guideline cannot be supported by the existing SCI literature, correction of hypotension in the setting of acute human SCI is offered as a strong treatment option. Class III evidence from the literature suggests that maintenance of MAP at 85 to 90 mm Hg after ASCI for 7 days is safe and may improve spinal cord perfusion and, ultimately, neurological outcome.