Adult thoracolumbar deformity is not just a “crooked back”. It can lead to chronic pain, loss of balance, difficulty walking and major limitations in everyday life. However, not everyone with a spinal curve needs surgery. This article is intended to help you understand when corrective surgery may make sense, what alternatives exist and which outcomes are realistic.
Thoracolumbar deformity surgery can improve pain and function in well selected patients, but it is a major procedure, with relevant risks and a prolonged recovery. Decisions are based on a combination of symptoms, imaging findings and overall health status, never on the X-ray alone.
Summary
- Not all thoracolumbar deformities require surgery; many can be managed with conservative treatments.
- The most frequent reasons to consider an operation are disabling pain, loss of balance and neurological involvement.
- Adult deformity surgeries are complex and carry a significant complication rate, which can exceed 30 percent in some series.
- Enhanced Recovery After Surgery (ERAS) pathways and good medical preparation reduce risks and speed up return to daily life.
- This text is informative and does not replace a personalised assessment by spine specialists.
What is thoracolumbar deformity in adults
The thoracolumbar spine is the transition zone between the thoracic region (where the ribs attach) and the lumbar region. A deformity in this area can take different forms:
- Degenerative adult scoliosis: a lateral curve that appears or progresses with age due to wear of the discs and joints.
- Thoracolumbar kyphosis: an increased forward curve, sometimes due to osteoporotic fractures or previous surgery.
- Sagittal imbalance: the trunk leans forward or to one side, forcing the patient to flex knees or hips to stand upright.
The main cause is usually progressive wear of discs and joints, although factors such as osteoporosis, connective tissue disorders, untreated childhood deformities or previous surgery with loss of spinal balance also play a role.
Guidelines and reviews on adult spinal deformity agree that this is not just a cosmetic issue: if not managed properly, spinal malalignment is associated with pain, functional limitation and poorer quality of life.
Symptoms and red flags: when to suspect that thoracolumbar deformity is relevant
Many people live with small curves and no major symptoms. Signs that suggest a clinically relevant deformity include:
- Chronic low back or thoracolumbar pain that worsens when standing or walking and improves when sitting or lying down.
- Feeling “unable to stand upright”: the trunk visibly leans forward or to one side.
- Progressive loss of height and the appearance of a “hump” or changes in the back silhouette.
- Walking intolerance: the need to stop every few minutes because of pain or weakness in the legs.
- Tingling, loss of strength or clumsiness in the legs, which may indicate compression of the spinal cord or nerve roots.
- Frequent falls or difficulty maintaining balance.
If neurological symptoms appear (loss of strength, sphincter problems, sudden loss of sensation), it is important to seek urgent medical attention to rule out significant compression of the spinal cord or nerve roots.
How thoracolumbar deformity is diagnosed
The assessment of a thoracolumbar deformity goes beyond a simple X-ray. It usually includes:
- Detailed medical history: duration of pain, impact on daily life, previous fractures, past surgery and comorbidities (diabetes, heart disease, osteoporosis, etc.).
- Physical examination: posture, gait imbalance, muscle strength, reflexes and sensation.
- Standing full-spine radiographs (long-cassette X-rays) in front and side views to measure sagittal and coronal balance.
- Magnetic resonance imaging (MRI) to assess discs, spinal cord and nerve roots.
- CT scan when more detail of the bone anatomy is needed, to plan osteotomies or to assess previous fusions.
- Measurement of spinopelvic parameters (for example, T1 pelvic angle, global sagittal alignment), which helps decide the type of correction required.
In recent years, studies have highlighted the importance of analysing the deformity as a whole (spine and pelvis) and not only the local curve, since global imbalance correlates well with the degree of disability and pain reported by patients.
Non surgical treatments: when it is still early to talk about surgery
Before considering thoracolumbar deformity surgery, conservative management is optimised whenever reasonable. Some measures include:
- Physiotherapy and therapeutic exercise: specific programmes to strengthen the trunk, stretching, balance training and postural re-education.
- Pain management: analgesics, anti inflammatory drugs, neuromodulating medications and, in selected cases, image guided injections.
- Osteoporosis control: vitamin D and calcium supplements, antiresorptive or anabolic drugs, and management of risk factors such as smoking.
- Weight loss and control of comorbidities (diabetes, hypertension, heart disease) to reduce the impact of pain and improve functional capacity.
- Bracing in very selected situations, usually as temporary support and never as the only solution.
In mild scoliosis or kyphosis, or when pain can be controlled and quality of life is acceptable, guidelines recommend prioritising these strategies and reserving surgery for cases in which the expected benefit clearly outweighs the risks.
When corrective thoracolumbar deformity surgery is considered
In general terms, surgery is considered when several factors come together:
- Severe or disabling pain that persists despite well conducted conservative treatment over several months.
- Significant malalignment (for example, a very forward pitched trunk or a marked lateral curve) that makes basic tasks such as walking or standing difficult.
- Documented neurological compression on imaging, with symptoms such as weakness, sensory loss or gait disturbances.
- Progression of the deformity documented on serial radiographs.
- Reasonable overall health to undergo major surgery: biological age, cardiopulmonary function, bone density, nutritional status and mental health are all evaluated.
Recent publications emphasise that patient selection is crucial. The same degree of deformity does not justify the same surgery in all people: the goal is to rebalance the spine so that the improvement in quality of life clearly compensates for perioperative and long term risks.
Types of surgery used to correct thoracolumbar deformity
Specific techniques are tailored to each case, but broadly speaking, three elements are combined:
- Decompression: relieving pressure on the spinal cord and nerve roots (laminectomies, foraminotomies) when there is significant compression.
- Fusion and instrumentation: placing screws, rods and other implants to stabilise the spine in the new corrected position.
- Osteotomies: controlled cuts in the bone to restore alignment when the deformity is rigid.
In many cases, surgery involves several levels and may extend from the upper thoracic region down to the sacrum or pelvis. Decisions about how far to fuse, what degree of correction to aim for and whether to operate in one or several stages depend on the specific deformity, bone quality and the patient’s general condition.
Minimally invasive techniques and lateral approaches (such as XLIF or OLIF) are used in selected cases, especially in less rigid curves or when the goal is to reduce blood loss and muscle damage, but they are not a universal solution.
Expected benefits versus risks and adverse effects
Potential benefits of well indicated thoracolumbar deformity surgery include:
- Reduction of mechanical pain associated with the deformity and overload of compensatory segments.
- Improved balance and ability to stand and walk, leading to greater independence in daily life.
- Prevention of further deformity progression in many cases, by stabilising the spine in a more functional position.
- Improved perceived quality of life, measured with specific questionnaires for adult deformity.
However, the literature on adult deformity surgery shows overall complication rates that may range between 30 and 50 percent, including both medical and surgical complications. The most common are:
- Wound complications: superficial or deep infections, wound healing problems.
- Neurological complications: new motor or sensory deficits, usually infrequent but potentially serious.
- Mechanical problems: pseudarthrosis (failure of the fusion to consolidate), screw or rod breakage, excessive kyphosis or lordosis in adjacent segments.
- Medical complications: cardiopulmonary events, venous thrombosis, decompensation of pre existing conditions.
Recent studies highlight the importance of identifying risk factors (advanced age, obesity, osteoporosis, cardiac or pulmonary comorbidities, poor overall condition, fragile mental health) and addressing them before surgery to reduce complications and the need for reoperations.
ERAS pathways and preoperative preparation: how to reduce risks
Enhanced Recovery After Surgery (ERAS) protocols adapted to adult deformity surgery combine multiple measures before, during and after the operation. Their goal is to reduce surgical stress, shorten hospital stay and lower complication rates without increasing risk. Common strategies include:
- Prehabilitation: gentle exercises, breathing training and adapted strength work before surgery.
- Nutritional optimisation and correction of anaemia or other deficiencies.
- Smoking cessation and better control of chronic diseases.
- Multimodal analgesic protocols with less reliance on opioids.
- Early mobilisation within the first 24-48 hours after surgery, whenever it is safe to do so.
Recent trials and systematic reviews suggest that, in adult deformity surgery, implementing ERAS programmes is associated with lower complication rates, shorter hospital stays and faster functional recovery, although they do not completely eliminate risk.
Realistic recovery timelines
Recovery times vary according to the extent of surgery, age, bone quality and the presence of other conditions. As a rough guide:
- First days: stay in a ward or step down unit, pain control, starting to sit and stand with assistance.
- First 2-4 weeks: walking with support, gradually increasing independence at home, marked fatigue but with a tendency to improve.
- Weeks 4-8: many people resume light tasks and office work, with frequent rest breaks.
- 3-6 months: progressive consolidation of the fusion, expansion of the physiotherapy programme and return to more demanding activities according to progress.
- 12 months or more: full adaptation to the “new” spine and the achieved alignment may take a year or longer.
Medium and long term follow up studies show that functional results often continue to improve beyond the first year in many patients, but also that late complications (pseudarthrosis, adjacent level problems) may appear, making regular check ups necessary.
When to go to the emergency department after thoracolumbar deformity surgery
After surgery, it is essential to recognise warning signs that require a visit to the emergency department or rapid contact with the medical team:
- Sudden loss of strength or sensation in the legs or difficulty moving them.
- New onset sphincter disturbances (incontinence or retention of urine or stool).
- New, intense pain, especially if accompanied by fever or a general feeling of being unwell.
- Redness, warmth or discharge from the surgical wound.
- Shortness of breath, chest pain or painful swelling in one leg, which may indicate a cardiopulmonary or thrombotic problem.
In the presence of any of these symptoms, it is unwise to wait for the next scheduled check up: urgent assessment is preferable, even if it later turns out to be a minor problem.
Myths and realities about thoracolumbar deformity surgery
Myth 1: “If I have surgery, my spine will be like new.”
Reality: the main goal is to improve alignment, reduce pain and restore function, but it is unrealistic to expect every ache or discomfort to disappear, especially in people with multiple affected levels or other health problems.
Myth 2: “If the X-ray looks very bad, I definitely need surgery.”
Reality: decisions are not based on imaging alone. Some people with striking deformities and manageable symptoms are treated conservatively, while others with more moderate curves but severe disability may clearly benefit from surgery.
Myth 3: “Surgery always makes things worse in people over 70.”
Reality: chronological age is only one factor. Overall functional reserve is what really matters. In selected older patients, surgery can improve independence and quality of life, although risks are higher and must be explained in detail.
Myth 4: “Once I have been operated on, the deformity cannot come back.”
Reality: there is a risk of implant failure, pseudarthrosis or decompensation of adjacent segments. That is why follow up, bone protection and appropriate rehabilitation are so important.
Myth 5: “If I am in pain, the only option is a long fusion.”
Reality: in many cases there are less aggressive alternatives (optimised conservative care, limited decompression, segmental surgeries) that are considered before indicating long fusions.
Frequently asked questions
Do I always need deformity surgery if I have scoliosis or kyphosis?
No. Many mild or moderate deformities can be managed with exercise, physiotherapy, pain control and regular monitoring. Surgery is considered when pain or malalignment significantly affects quality of life and conservative treatment is no longer sufficient.
Which imaging tests are essential before deciding on surgery?
At a minimum, standing full spine X-rays (front and side views) and an MRI to assess the spinal cord and nerve roots. In many cases, a CT scan is added to plan instrumentation and, if there is osteoporosis or previous surgery, the work up is completed with bone studies and specific blood tests.
What is the real risk of complications with this type of surgery?
It depends on the complexity of the deformity and the patient’s overall condition, but large series of adult deformity surgery describe overall complication rates above 30 percent, including medical, infectious and mechanical issues. This is why it is so important to individualise the indication and optimise preparation for surgery.
Will I be able to return to work after corrective thoracolumbar surgery?
For office based jobs, many people return to work between 8 and 12 weeks, with adjustments and frequent breaks. Physically demanding jobs that involve lifting and repetitive movements usually require more time and, in some cases, a change in role or occupation. The final decision is always made together with the medical and rehabilitation teams.
Does deformity surgery also treat osteoporosis?
No. Surgery can stabilise and realign the spine, but it does not treat the underlying bone fragility. It is essential to maintain specific treatment for osteoporosis before and after surgery, as bone quality influences implant stability and the risk of new fractures.
What role does mental health play in surgical outcomes?
Mental health has a major impact on pain perception, adherence to rehabilitation and satisfaction with the result. Recent studies show that untreated depression and anxiety are associated with worse perceived outcomes. It is therefore advisable to identify and address these factors before surgery.
Are there minimally invasive alternatives for all deformities?
No. Minimally invasive techniques and lateral approaches can be very useful for certain curves and in patients with good bone quality, but in very rigid deformities or in cases with marked sagittal imbalance, more extensive osteotomies and fusions with open or combined approaches are often required.
How long will the implants last?
Implants are designed to be permanent, but their long term performance depends on bone quality, the degree of correction and the loads applied to the spine. If the fusion consolidates well, it is uncommon to remove them, except in specific complications.
Glossary
- Thoracolumbar deformity: abnormal alignment of the spine in the transition zone between the thoracic and lumbar regions.
- Degenerative adult scoliosis: lateral curve that appears or progresses with age due to wear of the discs and joints.
- Kyphosis: increased forward curve of the thoracic or thoracolumbar spine.
- Sagittal balance: alignment of the spine when seen from the side, related to the ability to stay upright without excessive effort.
- Spinal fusion: permanent union of several vertebrae using bone graft and implants.
- Osteotomy: controlled cut of the bone to correct a rigid deformity.
- Pseudarthrosis: failure of a fusion to consolidate, which may cause pain and implant failure.
- ERAS programme: set of measures before, during and after surgery to reduce complications and speed up recovery.
References
This article is based on clinical guidelines and recent reviews on adult spinal deformity and spine surgery. Key references include:
- North American Spine Society. Clinical Guidelines for the Diagnosis and Treatment of Adult Spinal Disorders. NASS; 2021-2024. Available in the Clinical Guidelines section of NASS.
- NICE. Lateral interbody fusion in the lumbar spine for low back pain (IPG574). National Institute for Health and Care Excellence; last reviewed in 2017, with updated information for patients and professionals.
- Akıntürk N, et al. Complications of adult spinal deformity surgery: a literature review. 2022. Review of more than 26,000 patients, reporting overall rates of medical and mechanical complications.
- Arora A, et al. Preoperative medical assessment for adult spinal deformity surgery. 2023. Review of risk factors for perioperative complications in adult deformity.
- Fujii T, et al. Enhanced Recovery After Surgery Protocol in Patients With Adult Spinal Deformity: systematic review and meta-analysis. 2025. Analysis of ERAS programmes and their impact on complications and length of hospital stay.
- Berven SH, et al. Late Complications and Adverse Events in Adult Deformity Surgery. 2025. Review of late complications, implant failure and the need for reoperation in deformity surgery.
This content is for informational purposes only and is not a substitute for an individual assessment by qualified healthcare professionals. If you have any questions about your own situation, please consult your family doctor or a spine specialist.
