Adult degenerative scoliosis: challenges in diagnosis, pain management, and surgical decision-making

Adult Degenerative Scoliosis (ADS) is an age-related, progressive, three-dimensional spinal deformity driven by asymmetric degeneration of the intervertebral discs, facet joints, and supporting soft tissues. With population aging, ADS is increasingly recognized as a major contributor to pain, disability, loss of independence, and healthcare utilization.

This narrative review synthesizes evidence around three core challenges in the clinical management of ADS: (1) diagnostic difficulty due to heterogeneous etiology and symptom overlap with other degenerative conditions, (2) multidimensional chronic pain requiring multimodal, longitudinal strategies, and (3) high-stakes surgical decision-making that must balance deformity correction against complication risk and patient expectations.

We integrate contemporary concepts from adult spinal deformity classification and alignment targets, clinical and imaging assessment, and both nonoperative and operative treatment pathways. Particular emphasis is placed on standing full-spine radiographs and spinopelvic parameters, the mixed mechanical and neurogenic pain phenotypes that typify ADS, and stratified surgical strategies ranging from decompression alone to long-segment fusion with osteotomy. We also summarize major complications (e.g., proximal junctional kyphosis, pseudarthrosis, implant failure, infection) and their implications for counseling and risk mitigation.

ADS care benefits from a patient-centered, individualized, and multidisciplinary strategy. Future work should prioritize accurate prognostic models, minimally invasive and alignment-restoring techniques with lower morbidity, and durable approaches for long-term pain control and function preservation.