Adult Spinal Deformity Surgery

What is it?

Your spine is a stack of bones called vertebrae. With age, the discs and joints between them can wear unevenly. The spine may bend to the side, twist, or lose the normal inward curve of the low back. When the spine tips forward, many people bend their knees or lean on a cart just to stand up. This tires the muscles and can cause back pain, leg pain and trouble walking.

Doctors call this adult spinal deformity. In a large European study, people with adult spinal deformity scored worse on a standard quality-of-life survey than people with arthritis, chronic lung disease, diabetes or heart failure. A landmark study found that the more the spine tips forward, the worse pain and function tend to be.

The surgery is called posterior spinal fusion and reconstruction. "Posterior" means the surgeon works through the back. "Fusion" means joining bones so they heal together. Screws go into the vertebrae and connect to metal rods. The rods hold the spine in a better position while the bone heals.

Who might need it, and who usually doesn't?

Surgery may be an option for adults who:

• have pain, leg symptoms, or trouble standing and walking that limit daily life
• have tried non-surgical care without enough relief
• have a curve or forward tilt that is getting worse, or pressure on nerves that causes weakness
• are healthy enough for a long operation

Surgery is usually not the first choice for people who:

• have a curve on X-ray but few symptoms
• are happy with how they feel and function. Experts advise that non-surgical care makes sense for these patients, because surgery is less likely to make them better.
• have health problems that make major surgery too risky. For example, severely frail patients had about 4 times the odds of a major complication.

What are the alternatives, including non-surgical care?

Non-surgical care may include physical therapy, a walking or core-strength program, pain medicines, and injections near irritated nerves. Treating weak bones (osteoporosis) is also important.

In studies, non-surgical care usually kept pain and disability about the same over 2 years. It did not clearly improve them. Trying non-surgical care first is reasonable for many people. In a long-term study, many patients who started with non-surgical care chose surgery later.

Evidence note: Non-surgical care in these studies varied a lot from patient to patient. We do not know which non-surgical plan works best.

What happens before surgery?

Imaging. You will have full-length standing X-rays. These pictures show your whole spine, from neck to hips, while you stand. They let the surgeon measure how your spine and pelvis line up. You may also need a CT scan (a detailed 3-D X-ray) or an MRI (pictures of nerves and discs).

Bone density. Weak bones can make screws loosen. A national spine surgery guideline recommends checking bone health in people at risk for osteoporosis, with a bone density (DEXA) scan or CT. Some patients start a bone-building medicine before surgery. A 2025 review linked one such medicine, teriparatide, to higher fusion rates.

Smoking. In one study of complex deformity surgery, 19.2% of smokers had heavy bleeding during surgery, compared with 3.7% of nonsmokers. Quitting at least 4 weeks before surgery lowers lung and wound problems.

Diabetes. A national guideline advises extra counseling about infection and repeat-surgery risk when HbA1c (a 3-month blood sugar test) is above 7.5%. In a review of many studies, HbA1c above 8% was linked to about 1.85 times the risk of complications.

Nutrition. Low blood protein (albumin below 3.5 g/dL) raises the risk of infection, wound problems and poor bone healing. In one small study, nutrition support before surgery cut medical complications from 53.6% to 25%. Evidence note: This was one small study.

Medical check. Your heart, lungs, kidneys and overall strength are checked. Your other doctors may help you get ready.

What happens during surgery?

You are fully asleep (general anesthesia) and lie face down. The surgeon makes a cut down the middle of your back. Screws are placed in the spine bones. Stiff joints may be loosened, or small pieces of bone removed, so the spine can be moved into better alignment. This is called an osteotomy (see the spinal osteotomy guide). Rods are shaped and attached to the screws. Bone graft is placed so the bones grow together.

Nerve signals are often watched during surgery to help protect the spinal cord and nerves. Some patients have an extra incision on the side or front of the body, or surgery done in two stages. The operation usually takes several hours, and some patients need a blood transfusion.

What are the risks?

This is major surgery. Complications are common. Most can be treated, but some are serious.

• Any complication: In a large study that followed patients for 2 years, 69.8% had at least one complication. A review of more than 12,000 patients found complications in 24% to 36% around the time of surgery, plus another 11% to 15% later. Evidence note: Studies count complications differently, so rates vary widely. Data from two large registries show that major complications fell between 2010 and 2016.
• Another surgery: About 1 in 4 patients needed another operation within 2 years. In a long-term study, 37% of patients who had surgery had needed another operation by 8 years.
• Problems above the fusion (proximal junctional kyphosis): The spine just above the rods can bend forward over time. A review of 8,367 patients found this in 31.65%, with a more serious form (failure) in 11.41%. Not everyone with this problem has symptoms or needs more surgery.
• Broken rods or bone that does not heal: In 526 patients fused to the pelvis, 18.3% had a rod fracture.
• Nerve problems: In complex cases, 23% had new leg weakness when they left the hospital, and about 10% still had it at 2 years. Evidence note: This study included only the most complex surgeries. Risk is likely lower for less complex cases.
• Infection: A review of more than 200,000 spine operations found deep infection in about 1.5%. Rates may be higher after large deformity operations.
• Medical problems (patients 65 and older): pneumonia 5.9%, blood clots in the leg 4.1%, blood clots in the lung 3.2%, stroke 2.1%, heart attack 1.8%.
• Death: In a nationwide study from Denmark, 0.9% of patients died within 90 days.

What is recovery like?

Hospital stay. The average stay was 8.1 days in one large study. In Denmark, half of patients stayed between 7 and 11 days. Many patients spend time in intensive care first: 76% in one study. Some go to a rehab center before home.

Walking. A therapist helps you get up and walk soon after surgery. Walking is the main exercise early on.

The first weeks. It is normal to feel worse before you feel better. In one study, disability scores at 6 weeks were slightly worse than before surgery, then improved a lot by 1 year.

Driving and work. In a study of fusion to the pelvis, 97.4% returned to driving, on average about 4 months after surgery. Of those who worked, 88% returned, on average about 5.4 months after surgery. Do not drive while taking opioid pain medicine.

Final result. Most improvement happens in the first year. Results at 2 years are a good guide to results at 5 years. Some patients keep improving for up to 5 years.

What results can patients expect?

Results vary from person to person. No one can promise a specific result.

• In a major multicenter study, 77% of patients who had surgery reached a meaningful improvement in disability at 2 years, compared with 38% of patients treated without surgery.
• At 8 years, people who had surgery still had less disability, on average, than people who did not. The benefit was smaller in patients who had 2 or more serious complications.
• In a study that followed patients for an average of 4 years, back pain dropped from 7.1 to 3.8 on a 0-to-10 scale.
• At 2 years, 4.1% of patients felt worse, and 6.5% said they would not choose surgery again.

Evidence note: The best comparison study let patients switch groups, and many did. So most of the comparison comes from looking at what treatment patients actually got, not a strict randomized trial.

Fusion also means the fused part of your spine will no longer bend. If the fusion goes to the pelvis, some tasks, like putting on socks, may need new techniques or tools.

Questions to ask your surgeon

• Why do you recommend surgery now, and what is likely to happen if I wait?
• How many levels will be fused, and will the fusion go to my pelvis? How will that change bending, sitting and daily tasks?
• Will I need one surgery or two, and will there be incisions other than on my back?
• How do my bone density, smoking, blood sugar and weight affect my risk? What should I fix first?
• Which complications are most likely for someone like me?
• What will the first 3 months look like, and how much help will I need at home?
• How will you follow my spine over the years, and which symptoms mean I should call right away?

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