One hundred and fifty three patients who had sustained a spinal cord injury more than 20 years previously were assessed neurologically and by MRI scanning of their spinal cords. The spinal cord pathologies shown were, in order of prevalence, extended atrophy, malacia, syrinx, cyst, disruption and tethering. There was no relationship between the prevalence of any type of pathology and the degree of spinal canal compromise or angulation of the spine adjacent to the level of injury. Neurological changes after initial neurological stabilisation were seen only in patients with extended atrophy, malacia or a syrinx, not in those with only a cyst or cord disruption. Tethering is always associated with other lesion(s). Longer syrinxes were more likely to have associated neurological changes than shorter ones. The most common neurological change was pain.