The degenerating intervertebral disc leading to structural failure of the aging spine: from cellular pathways, risk factors, radiological diagnosis, to surgical management.

Low back pain is a leading cause of disability worldwide. While non-specific low back pain accounts for the majority of cases, older adults are at increased risk of pathological and structural causes related to age-associated spinal degeneration, including intervertebral disc degeneration. Despite widespread use, conventional diagnostic imaging often fails to reliably identify pain-generating sources. Treatment decisions remain challenging, with many current interventions providing limited long-term efficacy. This perspective reviews the cellular pathways and risk factors contributing to disc degeneration specifically in an aging spine. Mechanical degeneration within the spine is explored alongside a correlation to pain generating sources. The role of surgical treatment is explored alongside emerging techniques and contributors to enhanced outcomes. Intervertebral disc degeneration reflects molecular, cellular, and biomechanical changes within the spine that are increasingly prevalent in an aging population. Recent advances in the understanding of the pathophysiology of disc degeneration reveal a complex relationship between intrinsic aging and the role of the exposures in progressive degeneration. Radiological evaluation remains limited in diagnostic certainty though emerging technologies offer improved identification of pain generating sources and may offer trajectory tracking of spinal pathologies. Evolving surgical techniques and patient selection may improve outcomes in patients that require structural intervention in their aging spine.