Exosome-mediated repair of spinal cord injury (SCI) is a promising therapeutic strategy. SCI causes severe sensory and motor dysfunction and is challenging to treat due to complex pathological mechanisms. Exosomes, small extracellular vesicles (30–150 nm), play a key role in intercellular communication and are ideal for drug delivery. They contain nucleic acids and proteins that can repair SCI by modulating inflammation, promoting axonal regeneration, and reducing apoptosis. Various exosomes, including those from neural stem cells, Schwann cells, mesenchymal stromal cells, and macrophages, have shown potential in SCI repair through different mechanisms, such as promoting angiogenesis, anti-inflammatory effects, and antioxidant activity. Exosomes can be administered via intravenous, local, intranasal, or intravitreal routes, with intravenous injection being the most common. However, challenges remain, including low exosome yields, poor targeting, and the need for standardized extraction methods. Exosomes combined with hydrogels or drug-loaded exosomes show promise for improving SCI repair. Despite these challenges, exosomes offer a novel approach for SCI treatment due to their biocompatibility, stability, and ability to deliver therapeutic agents. Further research is needed to optimize exosome production, improve targeting, and establish clinical applications for SCI repair.Exosome-mediated repair of spinal cord injury (SCI) is a promising therapeutic strategy. SCI causes severe sensory and motor dysfunction and is challenging to treat due to complex pathological mechanisms. Exosomes, small extracellular vesicles (30–150 nm), play a key role in intercellular communication and are ideal for drug delivery. They contain nucleic acids and proteins that can repair SCI by modulating inflammation, promoting axonal regeneration, and reducing apoptosis. Various exosomes, including those from neural stem cells, Schwann cells, mesenchymal stromal cells, and macrophages, have shown potential in SCI repair through different mechanisms, such as promoting angiogenesis, anti-inflammatory effects, and antioxidant activity. Exosomes can be administered via intravenous, local, intranasal, or intravitreal routes, with intravenous injection being the most common. However, challenges remain, including low exosome yields, poor targeting, and the need for standardized extraction methods. Exosomes combined with hydrogels or drug-loaded exosomes show promise for improving SCI repair. Despite these challenges, exosomes offer a novel approach for SCI treatment due to their biocompatibility, stability, and ability to deliver therapeutic agents. Further research is needed to optimize exosome production, improve targeting, and establish clinical applications for SCI repair.