Spinal cord injury (SCI) often results in severe motor, sensory, and autonomic dysfunction below the injured level, and even death. Due to the complexity and diversity of its pathological mechanism, there are no successful clinical treatments. In recent years, microRNAs (miRNAs) have received more and more attention in the treatment of SCI. Exosomes are the key communication media between cells and tissues that transfer nucleic acids, proteins and lipids. miRNAs, as the main contents of exosomes, participate in various pathophysiological processes of SCI. A large number of studies have shown that exosomal miRNAs are not only effective in the treatment of SCI, but also could be used as biomarkers for the early diagnosis of SCI.