Traumatic brain and spinal cord injuries continue to pose serious challenges for physicians around the world. In North America, the annual number of serious head and spinal injuries has decreased over the last two decades, and of those patients who reach a hospital, the mortality and long-term morbidity have also declined. The two major reasons for this reduction in death and disability after craniospinal trauma in the United States and Canada appear to be (1) widespread implementation of prevention measures, safety legislation, and public education initiatives; and (2) further improvements in and wider availability of emergency medical systems and regional trauma centers. Improvements in neurocritical care and the implementation of evidence-based treatment guidelines for severe head injury victims may also, in part, be responsible for improved survival rates and reduced disability rates. Unfortunately, numerous clinical trials of putative neuroprotective agents conducted in North America and elsewhere during the 1990s have failed to demonstrate efficacy in head-injured patients. However, methylprednisolone does appear to confer some benefit to a select population of spinal cord injury patients. These advances in the areas of prevention, regional trauma systems, treatment guidelines, and neurocritical care that have influenced survival rates and recovery of function are discussed.