The most common indications for surgery in adults with scoliosis or kyphosis are debilitating pain from the deformity or associated spinal stenosis with neurological symptoms. Other indications include documented progression of deformity or instability that hinders erect posture. Although surgery may be considered in the adolescent with spinal deformity to prevent long-term development of restrictive lung disease or cor pulmonale (which may occur in patients with scoliosis > 90–100°), adult deformity correction surgery is rarely if ever indicated to improve established cardiopulmonary impairment. In fact, spinal deformity surgery in the adult may actually lead to long-term deterioration of pulmonary function, particularly if the chest is entered during the approach.

Because of the potential for major physiologic insult, an extensive preoperative medical work-up should be conducted when indicated in the patient considering surgery for spinal deformity correction. The combination of careful preoperative screening, risk stratification, and medical optimization in consultation with medical specialists is paramount to successful outcomes. Depending on the magnitude of associated comorbidities, the surgical procedure may need to be appropriately curtailed to address the underlying medical conditions. Therefore, complete correction of the deformity may not be achieved. However, because adequate correction of deformity (in particular, deformity in the sagittal plane) has been shown to be associated with significantly better outcomes, the majority of operations for spinal deformity should be designed to achieve, at a minimum, the restoration of spinal balance in both the coronal and sagittal planes.