Background There is no method in clinical use for measuring intraspinal pressure (ISP) and spinal cord perfusion pressure (SCPP) after traumatic spinal cord injury (TSCI) in humans. I hypothesised monitoring ISP and optimising SCPP may improve spinal cord function after injury. The thesis was performed in three stages. Methods (1) I ascertained the views of consultant neurosurgeons and neuroanaesthetists on the acute management of TSCI , via a survey. (2) A pressure probe was placed subdurally at the injury site in 18 patients with severe TSCI. Recording commenced within 72 hours of injury and continued for up to one week. Spinal cord blood flow was assessed using indocyanine green fluorescence, and spinal cord function using a limb motor score, motor evoked potentials (MEPs) and an index of autoregulation (sPRx). I explored the effect of different treatments on SCPP. (3) 134 magnetic resonance (MR) scans from 93 TSCI patients were analysed. In 14 patients with motor complete TSCI, I evaluated the effect of laminectomy on ISP, SCPP and compensatory reserve (sRAP). Results (1) The acute management of TSCI by U.K. neurosurgeons and neuroanaesthetists is highly variable, both surgically and in intensive care. (2) There were no procedure related complications with ISP monitoring. ISP was higher in 18 TSCI patients compared to 12 subjects without TSCI. Changes in PC02, sevoflurane concentration and mannitol administration had no significant effect on ISP or SCPP. Inotropes increased ISP with a net increase in SCPP. Increasing SCPP increased MEP amplitude and ICG fluorescence in some patients. (3) On MR, 26% TSCI patients had dural compression. Compared with intact lamina patients, the laminectomy group had lower ISP, comparable SCPP and comparable sRAP. In the laminectomy group, ISP remained high (>20mmHg) 41% of the time, and SCPP low «60mmHg) 24% of the time. Conclusions I provide proof-of-principle that subdural intraspinal pressure at the injury site can be measured with low risk after TSCI. Optimising SCPP improves motor function in some patients. The dura is responsible for spinal cord compression in a quarter of patients. Though bony realignment with laminectomy reduces ISP, it does not effectively decompress the spinal cord and does not increase spinal cord perfusion.