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STUDY DESIGN Patients who had suffered from acute blunt cervical spinal cord injury (SCI) and admitted our hospital within 24 hours after injury were included in the study. OBJECTIVE We compared the respiratory function and serum reactive oxidative stress (ROS) after acute cervical SCI, and tried to find out the valuable predictors of weaning in acute cervical SCI patients. SUMMARY OF BACKGROUND DATA Ventilation impairment is a major complication of acute cervical SCI. Evidence of oxygen radical formation in secondary injury from animal SCI models demonstrates an immediate post-injury increase in ROS production after SCI. We hypothesis the serum ROS is associated with the severity of patients with acute cervical SCI. METHODS 38 adult patients who had acute cervical SCI and 58 healthy volunteers were enrolled. Respiratory function at admission, at the time of extubation and at 48 hours after extubation, serum oxidative stress, Injury Severity Score (ISS) and Japanese Orthopaedic Association (JOA) score at admission were compared. RESULTS The most notable predictor of mechanical ventilator > 48 hours was serum thiobarbituric acid-reactive substances (TBARS) level at admission (p = 0.027), and the cut-off value of serum TBARS level was 731.7 μmol/L (sensitivity 87.5% and specificity 78.9%). For the re-ventilation ≤ 5 days, the notable predictors were respiratory function at the time of extubation (maximal inspiratory pressure (MIP), p = 0.040; maximal expiratory pressure (MEP), p = 0.020; and tidal volume (TV), p = 0.036) and serum TBARS level at admission (p = 0.013), the cut-off value of serum TBARS level at admission was 762.3 μmol/L (sensitivity 100% and specificity 90.0%). CONCLUSIONS In this study, respiratory function (MIP, MEP and TV) at the time of extubation can be useful optimal clinical guidelines for weaning and extubation attempts in patients with acute cervical SCI. Serum TBARS level at admission can be a useful predictor for severity in acute cervical SCI patients. LEVEL OF EVIDENCE 3.