Spinal cord injury (SCI) involves a spectrum of debilitating conditions, impacting motor, sensory, and autonomic functions. Tetraplegia and paraplegia are common classifications, with cervical SCI representing a significant portion of cases. Metabolic and nutritional challenges arise in critically ill SCI patients, necessitating tailored interventions to optimize outcomes. Hypermetabolism, driven by inflammation and tissue repair, demands increased caloric intake during the acute phase. Dysregulation of the sympathetic nervous system further complicates metabolic disturbances. Muscle metabolism undergoes profound changes, with mitochondrial dysfunction and disuse atrophy contributing to muscle wasting. Hormonal imbalances exacerbate muscle catabolism, leading to sarcopenia and functional impairment. Understanding these complexities is crucial for delivering personalized nutritional support to mitigate complications and enhance the quality of life in SCI patients. This chapter explores clinical strategies to address metabolic dysregulation and muscle wasting, offering insights for improving outcomes in this vulnerable population.