The repair and functional regeneration of spinal cord injury (SCI) remains a major challenge and focal point in regenerative medicine. Following SCI significant inflammation and neuronal damage occur. Conventional drug therapies often fail to precisely target the injured areas and cannot cross the blood-spinal cord barrier, severely limiting therapeutic efficacy. Therefore, precision therapeutics are crucial to improve the prognosis of SCI patients. In recent years, exosomes have gained widespread attention as natural delivery vehicles due to their low immunogenicity, high biocompatibility, and efficient delivery capabilities. Exosomes can effectively cross cell membranes and target specific cells, playing an important role in intercellular signaling. This makes them highly promising for precision therapies in SCI. By engineering exosomes for targeted delivery, new strategies can be developed for drug delivery, gene therapy, and personalized treatment after SCI. We aimed to review the biological functions of exosomes derived from different cell sources and discuss the role in tissue repair following SCI. Additionally, we explore the prospects and potential of exosomes in clinical SCI applications, to provide valuable research insights to improve functional recovery and long-term health management for SCI patients in the future.