Gunshot wounds account for 13 to 17% of spinal injuries and are most common in the thoracic region, frequently result in complete paraplegia. The initial management of a patient with a gunshot wound must include the maintenance of airway, breathing and circulation. Gunshot wounds to the neck may be complicated by injuries to the neurovascular structures, airway and the esophagus. In the thoracolumbar spine, it can lead to life-threatening injuries to the heart, lungs, major blood vessels and bowel. In addition, sacral wounds may result in hemorrhage and injuries to the bladder and bowel. Septic complications following gunshot wounds to the spine including osteomyelitis, meningitis, intrathoracic or intra-abdominal abscesses may lead to catastrophic consequences and a poor response to treatment. Velmatros and Demetriosdes noted a 9.8% overall incidence of bullet wound-related sepsis in 153 patients. In 81 patients with retained bullets, the incidence of septic complications was 7.4%. The incidence of septic complications was significantly higher in the lumbar spine when compared to other regions. Gunshot wounds to the spine are complex injuries and treatment depends on the physician’s ability to understand the mechanism of injury, principles of acute management of life-threatening injuries and diagnostic imaging. Antibiotics are an important component of treatment and should be continued for a minimum of 7 days in wounds that perforate both the colon and injure the spine. Steroids are not recommended for spinal cord injuries following gunshot injuries. Bullet removal is recommended if it is causing progressive neurological deficit. A multidisciplinary team is vital in assessing and treating life-threatening injuries and following stabilization, rehabilitation is essential.