Background: Despite a consistent trend toward older age at time of spinal cord injury (SCI), little is known about the external causes of SCI in the elderly. Objective: To examine environmental circumstances, documented by International Classification of Diseases, 10th Revision, Clinical Modification codes, at time of SCI among older adults. Method: Data on individuals injured in 2005 or later were retrieved from the National SCI Database. Demographics, injury profiles, and external causes of injury were compared between the study group (age >60 years, n = 1,079) and reference group (age 16-45 years, n = 3,579) using chisquare and Student t tests. Results: Among the elderly, falls were the most common etiology of SCI (60%), followed by transport accidents (24%) and complications of medical and surgical care (12%). In the younger group, transport accidents were the most common etiology of SCI (49%), followed by falls (22%) and assault (21%). Falls on the same level (30%), from stairs and steps (22%), and other slipping, tripping, and stumbling (11%) were the most common mechanisms of falls in the elderly group. Among motor vehicle accidents, car occupant injured in a collision with another car was the most common mechanism of injury among the elderly (28%). Conclusion: There is an urgent need for effective fall prevention programs among the elderly to reduce SCI in this expanding population. Details on the mechanisms of falls and other major causes of SCI among the elderly provided in this study should inform the development of future interventions for high-risk persons, activities, and environments.