Back pain is a common symptom that can indicate serious disease, particularly in elderly patients. Separation of the serious pathologies such as malignancy, infection, and cauda equina syndrome from benign axial back pain is a challenge. The red flags have clinical use for assisting in obtaining key features in the history and examination that may relate to sinister pathology. Knowing what and when to refer to a spinal specialist, such as an orthopaedic surgeon or neurosurgeon, is important. Spinal stenosis, radicular pain, and vertebral compression fractures of the spine may require specialist skills in discectomy, decompression, and reconstruction. This article deals with the assessment and treatment of spinal stenosis, radicular pain, and vertebral compression fractures.