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

Background: 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. Objective: 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. Methods and key content: 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. Conclusion: 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.