Decision making in adult deformity.

Spinal deformity affects adults and adolescents in different ways. Adult deformity patients are skeletally mature and tend to have relatively fixed curves, whereas adolescent patients are skeletally immature with flexible curves. As a result, adult patients typically present with back pain and neurological concerns, whereas adolescents present with cosmetic complaints. The goals of surgery on the adult deformity patient are to treat pain and relieve neurological problems while maintaining or achieving three-dimensional balance. The absolute degree of coronal curve correction in an adult deformity patient is less important than maintaining good sagittal balance. Issues that must be addressed in the preoperative decision-making process include the approach to the surgery, the timing of the surgery, and the location of the end of the construct. Twenty years ago, anteroposterior surgery was the most common procedure used for adults with fixed curves; however, recent advances in technology and techniques have led to more frequent use of purely posterior approaches. The posterior approach allows for greater curve correction owing to two major advances in the surgical method: osteotomy techniques, which release fixed deformities, and pedicle screw instrumentation in the thoracolumbar spine, which achieves greater curve correction with fewer levels of fixation. The optimal timing of surgery and the levels to be treated remain open to debate. Each adult patient's treatment must be individualized to achieve the best coronal correction possible while maintaining sagittal balance to preserve the three-dimensional balance of the spine.