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Objective Sacral insufficiency fractures should be considered in differential diagnosis as a cause of autonomic dysreflexia and other vague symptoms in patients with spinal cord injury. Setting The Supra Regional Tertiary Centre, Midlands Centre for Spinal Injuries, Oswestry, UK. Method Outpatient clinic review of 2 patients with long-standing spinal cord injury presenting with vague symptoms of abdominal discomfort, and increased spasms including autonomic dysreflexia in which no evidence of causation was found on clinical examination. Result Radiological investigation with computed tomography of the abdomen and pelvis demonstrated sacral insufficiency fractures in both cases. These were managed conservatively and, following a diagnosis of osteoporosis, treatment with bisphosphonates was commenced. There was an improvement in symptomatology at the 12-week follow-up. Conclusion Longevity in spinal cord injury continues to improve with increased awareness and improved management. However, along with improved longevity, secondary complications may occur, including sacral insufficiency fracture, which is difficult to diagnose and can affect quality of life. An awareness of sacral insufficiency fracture and its possible occurrence as a differential diagnosis in patients with chronic spinal cord injury presenting with vague symptoms can result in early diagnosis. Conservative management with bed rest is a viable option. LAY ABSTRACT Longevity in patients with spinal cord injury continues to improve with increased awareness and improved management. However, along with improved longevity secondary complications may occur, including sacral insufficiency fracture, which is difficult to diagnose and can affect quality of life. An awareness of sacral insufficiency fractures and their possible occurrence as a differential diagnosis in patients with chronic spinal cord injury presenting with vague symptoms can result in early diagnosis. Conservative management with bed rest is a viable option.