The most common indication for surgery in adults with scoliosis or kyphosis is debilitating pain from the deformity or associated spinal stenosis with neurological symptoms. Other indications include documented progression of the deformity or instability that hinders erect posture. Disease that threatens cardiopulmonary function is rare, but significant restrictive lung disease or cor pulmonale may be seen in patients with scoliosis greater than 90–100 degrees, thoracic lordosis, or disorders that affect chest mechanics (muscular dystrophy, ankylosing spondylitis, etc.). When indicated, pulmonary function tests should be correlated to arm span rather than height in the deformity patient. If significant cardiac failure is present preoperatively, the prognosis for life is usually not improved by correcting the deformity and surgery may be ill-advised. If the deformity is progressive and severe enough (more than 45–50 degrees), it is often preferable to perform surgery during adolescence because in adults the complications are more frequent, rehabilitation more extensive, and the operative risk greater. However, in adult patients, debility from chronic severe pain may force consideration of surgical intervention even with significant comorbidity. Depending on the exact nature of the surgery, the physiologic insult sustained by the adult deformity patient may be on par with or exceed that of a liver transplant. As a result, careful preoperative screening, risk stratification, and medical optimization in consultation with medical specialists is paramount to successful outcomes.

Either a posterior, anterior, or combined operative approach may be used.