Back pain after 65: when it is mechanical and when it is not

Low back pain is the leading cause of years lived with disability worldwide. In younger adults, the overwhelming majority is non-specific — no identifiable structural cause, good prognosis, and imaging that finds abnormalities present equally in people with no pain at all.

That last point holds at every age and is worth stating plainly. Disc degeneration is present in around 90 per cent of people over sixty on MRI regardless of symptoms. Disc bulges, facet arthritis and endplate changes are near-universal findings. A scan report describing them is describing an ageing spine, not necessarily explaining a pain.

What changes after sixty-five is the pre-test probability of the exceptions.

The specific causes that become more common

Lumbar spinal stenosis. Narrowing of the spinal canal, usually from a combination of disc bulging, facet hypertrophy and ligament thickening. The characteristic history is neurogenic claudication: leg pain, heaviness or numbness brought on by walking and standing, relieved by sitting or bending forward. Patients often report they can push a shopping trolley much further than they can walk unaided, because leaning forward opens the canal. Walking uphill is easier than downhill for the same reason.

Vertebral compression fracture. Sudden onset of localised back pain, often after minimal or no trauma, in someone with osteoporosis. Height loss and increasing thoracic kyphosis over time are clues. These are frequently missed, and a substantial proportion are found incidentally on imaging done for other reasons.

Degenerative spondylolisthesis, where one vertebra slips forward on another, commonly at L4–L5 and more often in women.

Aortic aneurysm, which can present as back pain and is a diagnosis not to miss.

Malignancy and infection, both rare but disproportionately represented in this age group.

Why imaging early is still usually wrong

Even in older adults, routine imaging for uncomplicated back pain does not improve outcomes and reliably finds incidental abnormalities that lead to unnecessary intervention and to the belief that the spine is damaged.

That belief matters. Patients told they have a degenerating spine report more disability and are less likely to remain active, independent of what the imaging showed. Language in radiology reports has real clinical effects, and phrases like "severe degenerative change" are describing findings that are near-universal by seventy.

Imaging is appropriate when a red flag is present, when there is a progressive neurological deficit, when symptoms suggest stenosis severe enough to consider surgery, or when pain persists despite a proper course of conservative management.

What helps

Staying active. The single most consistent finding across the literature. Bed rest worsens outcomes. This is unwelcome advice when moving hurts, and it remains correct.

Exercise therapy — the evidence does not favour any one type strongly. Walking programmes, strength work, Pilates-style motor control training and general conditioning all outperform doing nothing, and the best predictor of benefit is whether the person will keep doing it.

For older adults specifically, hip and trunk strengthening matters, because weak hips shift load onto the lumbar spine, and thoracic mobility work helps counteract the kyphosis that develops with vertebral wedging.

For stenosis, flexion-based exercise — cycling, using an inclined treadmill, bending forward — is often better tolerated than extension. Some patients get real benefit from a walking programme structured around their tolerance, sitting before the pain forces them to.

Analgesia, used to enable activity rather than as the treatment. NSAIDs work modestly and carry more risk with age. Paracetamol has disappointing evidence for back pain specifically. Opioids are a poor choice for chronic back pain at any age and a particularly poor one here.

Injections and surgery

Epidural steroid injection for stenosis gives short-term relief in some patients, with limited evidence for lasting benefit. Facet joint injections have weak evidence.

Decompressive surgery for lumbar stenosis is effective in appropriately selected patients — those with clear neurogenic claudication, imaging that matches the symptoms, and failure of conservative treatment. Trials comparing surgery with non-operative care show a benefit for surgery that is largest early and narrows over several years. It is a reasonable operation for the right person and a poor one for back pain without leg symptoms.

Vertebroplasty and kyphoplasty for compression fractures have a genuinely contested evidence base, with sham-controlled trials producing conflicting results.

The thing worth checking

If back pain in an older adult began suddenly, without much of a cause, and is localised and severe — think about a compression fracture and about the bone density behind it. Finding one is not just an explanation for the pain; it is a marker of osteoporosis that substantially raises the risk of the next fracture, and it should trigger assessment and treatment rather than being managed only as a pain problem.