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Cross-sectional survey.The objective of this paper was to assess the reliability of surgeons’ decision-making in adolescent idiopathic scoliosis (AIS) based on patient photographs and clinical and radiographic data.Orthopedic spine surgeons rated severity of deformity as the most important surgical consideration in AIS. However, studies have shown that surgeon reliability is highly variable when rating physical deformity. Surgeons’ unreliable ratings of patients’ physical deformity may lead to inconsistent decision-making.Four pediatric spine surgeons viewed 40 patients with varying severity of AIS on three occasions, 2 weeks apart. In the first viewing, surgeons viewed only patient photos and body image scores. In the second viewing, surgeons viewed patient photos, body image scores, and clinical data. In the third viewing, surgeons viewed patient photos, body image scores, a 3-ft anteroposterior spinal radiograph, and corresponding radiographic data. After viewing each patient, surgeons were asked if: 1) spinal fusion with or without thoracoplasty would improve the patient’s appearance; and 2) whether they would recommend this patient for spinal fusion with or without thoracoplasty.Surgeons’ concordance in recommending patients for surgery and if they thought it would improve their appearance varied widely with kappa scores ranging from poor (0.34) to good (0.76). Recommendations for surgery were more consistent with the addition of radiographs but were not influenced by patients’ body image perceptions. Surgeons’ recommendations for surgery were also inconsistent with treatment actually received with overall kappa scores ranging from poor (0.32) to good (0.73).Surgical decision-making for AIS is inconsistent.