Design: An age-and gender-matched case-control study. Objective: To compare colonoscopy after spinal cord injury (SCI) with the general population in terms of indications, bowel preparation, technical success and disease detection. Setting: Victoria, Australia. Methods: Consecutive SCI colonoscopies between January 1998 and February 2013 were compared with a randomly selected ageand gender-matched control group. Injury level, indication for procedure and demographics were collected. Outcome measures included quality of bowel preparation, completion rates, procedural duration and benign and malignant disease detection. Results: A total of 440 colonoscopies were assessed, comprising 148 SCI patients and 292 age-and gender-matched controls. Both the groups were of similar age (54.7 years vs 54.5 years, P = 0.906) and comprised predominantly males (87.1% vs 86.3%, P = 0.919). SCI colonoscopies were more often performed to investigate abnormalities (85.1% vs 58.2%, Po0.001) than for screening or surveillance (18.2% vs 40.8%, Po0.001). Unsatisfactory bowel preparation was recorded more often in the SCI group (36.0% vs 13.0%, Po0.001) and completion rates were lower (75.7% vs 93.1%, Po0.001). Overall disease detection was lower in the SCI group (45.3% vs 59.6%, Po0.006). The polyp detection rate was lower for SCI (11.4% vs 25.3%, P = 0.001). The rate of diagnosis of malignancy was equivalent (2.7% vs 3.0%, P = 0.904). Conclusion: SCI patients have the same risk of malignancy as the general population and are less likely to undergo screening colonoscopy. Colonoscopy is then limited by poor bowel preparation and lower completion rates with a subsequent lower polyp detection rate. INTRODUCTIONThere is both an increasing prevalence and increasing average age of SCI patients. 1 Despite improvements in acute mortality, there is still a decreased life expectancy now most frequently attributed to cancer. 2 Colorectal cancer (CRC) screening in this group has received little attention despite reports of an at least equivalent cancer risk 3-5 and presentation with more advanced disease. 6 Detection of occult neoplastic disease is difficult due to higher rates of gastrointestinal complaints 6,7 and the high frequency of PR bleeding should exclude SCI patients from faecal occult blood testing. 3 Colonoscopy is challenging with difficulties in bowel preparation and low intubation rates despite multiday bowel preparation, 3,8,9 and studies assessing yield and safety of colonoscopy after SCI 3,8 have been limited by a small sample size or lack of a control group. We seek to highlight the difficulties with colonoscopy after SCI using a noninjured control group but to emphasise its importance by demonstrating the rates of benign and malignant diseases.