Self-reported back pain is common at any age; however, as a new symptom in elderly people it requires careful assessment because it may signal a serious disorder. The challenge is to maintain clinical vigilance for detection of cancer, infections or serious spinal disorders, since benign axial back pain affects a substantial proportion of the population. Red flags assist in obtaining key features in the history and examination that may relate to sinister pathology such as malignancy, infection and cauda equina syndrome. Knowing what and when to refer to a spine specialist such as an orthopaedic surgeon or neurosurgeon is important. Spinal-cord compression and loss of the structural integrity of the spine may require specialist skills for decompression and reconstruction. Management is often multidisciplinary, involving oncologists or infectious-disease specialists, and surgeons.