Contemporary open thoracolumbar approaches for anterior scoliosis correction and fusion have been modeled after the early technique popularized by John Hall from Boston Children’s Hospital in the late 1980s. The typical curve patterns for which this technique is most appropriate are thoracolumbar curves, which we now classify as Lenke V or VI curves. Patient selection and informed patient choice in choosing anterior versus posterior approaches need to be thoughtfully and thoroughly reviewed with the family. The patient depicted in Figure set 14-1 has a Lenke Vb thoracolumbar curve as depicted in Figure 14-1A and B radiographically and clinically in Figure 14-1C and D. Confirming that the patient’s proximal and distal curves are nonstructural is critical for restoration of the trunk shift demonstrated in Figure 14-1C. Her significant rib hump demonstrated in Figure 14-1E also responds favorably to the derotation effected by 270-degree annulotomy and discectomy and deliberate orthogonal placement of the screws relative to the native rotational axis of the vertebrae. Figure 14-1F and G demonstrate the contralateral locking nut that enhances proximal screw fixation. This concept and implant design was popularized by Dr. Izzy Liebermann while at the Cleveland Clinic in the late 1990s to address the troublesome rate of proximal screw pullout, loss of correction, and potential nonunion noted with the widespread adoption. Figure 14-1G demonstrates osseous union and the patient’s 1-year sagittal profile. Figure 14-1H and I demonstrate the 1-year clinical correction of coronal balance, level shoulders, waist symmetry, and reduction of rib hump on posteroanterior (PA) and forward bend photos. For this patient, a T9 to L2 anterior approach was utilized, whereas with a typical posterior approach, an additional distal segment may have been necessary.