Debate: Degenerative Scoliosis: To Operate or Not to Operate

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The operative treatment of adult lumbar degenerative scoliosis is a formidable challenge to the spinal deformity surgeon. Recent reports indicate that the major surgical complication rate of adult lumbar scoliosis fused to the sacrum ranges from 56% to 75%, and the unplanned reoperation rate ranges from 18% to 58%. In addition, complication rates are further increased by advanced age and medical comorbidities. The improvement in pain and physical activity achieved by fusion has not been as extensively published as other orthopedic procedures such as total hip arthroplasty. The decision to operate on an elderly patient with significant comorbidities must weigh the high complication and reoperation rates against anticipated improvement.
If surgery is contemplated, one must consider complete preoperative medical evaluation. Postoperative care also must involve an appropriate interdisciplinary team and include established care patterns for at-risk patients. The surgical procedure itself may need modification to achieve lesser goals than would be attempted in a more robust patient. An informed consent discussion should include the patient and her support group. Risks and complications must be fully understood, and the patient will ultimately choose between those risks and her quality of life. The surgeon should offer options and probabilities, but the patient must bear the consequences of that choice.

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