Surgical management of severe neglected adult idiopathic scoliosis: A review article on challenges and contemporary treatment strategies.

Neglected adult idiopathic scoliosis (NAdIS) is a spinal deformity characterized by severe rigidity and multiplanar curvature, significantly impairing pain levels, physical function, and health-related quality of life. Its complexity is heightened by longstanding vertebral malalignment, cardiopulmonary compromise, and age-related comorbidities, making surgical management particularly challenging. Despite progress in spinal deformity correction, consensus remains lacking on the optimal treatment strategy for these patients. This narrative review synthesizes contemporary surgical options for NAdIS, including posterior spinal fusion (PSF), posterior column osteotomy (PCO), halo-gravity traction (HGT), temporary internal distraction (TID), vertebral column resection (VCR), anterior release, multilevel lateral lumbar interbody fusion (LLIF), and novel posterior-only techniques such as posterolateral convex discectomy (PCDR) and intervertebral release (IVR). A structured decision-making framework is proposed, taking into account curve severity, location, flexibility, and patient-specific factors. Each technique offers unique advantages and limitations. PSF remains the foundational method for moderate, flexible curves. HGT is a valuable adjunct for enhancing spinal flexibility and pulmonary function in severe cases. TID provides a staged, safer alternative to VCR, enabling gradual correction while preserving spinal cord perfusion. VCR, although powerful for three-dimensional deformity correction, carries high morbidity and is generally reserved for rigid, sharply angulated curves. Anterior release retains value in select thoracic deformities, particularly those with anterior bridging or hypokyphosis. LLIF enables effective coronal realignment and vertebral derotation in thoracolumbar curves with preserved disc mobility. Posterior-only techniques such as PCDR and IVR have emerged as viable, less invasive alternatives to anterior release, especially when used at multiple apical levels. Recent advancements in technology-including 3D printing, intraoperative navigation, and robotic-assisted instrumentation-have further refined surgical planning and execution, offering enhanced accuracy and reduced complication rates. These tools are especially useful in navigating complex spinal anatomy and minimizing neurologic risk. The management of NAdIS necessitates a stepwise, individualized surgical strategy that balances deformity correction with patient safety and functional goals. While posterior-based approaches dominate current practice, selected cases benefit from anterior, staged, or combined interventions based on specific anatomical and physiological considerations. Future progress in the treatment of NAdIS will depend on the continued refinement of evidence-based algorithms and broader integration of enabling technologies. This review aims to support spine surgeons in delivering safe, personalized, and effective care for this uniquely challenging patient population.