Most of the adult degenerative deformity patients are advanced in age and present usually with many preoperative comorbidities, compromised general health, and reduced bone density. A valid assessment of the spine, globally, is crucial. Rather than attempting complete correction of deformity, the goal of surgical intervention in this population is relief of mechanical and neurogenic pain and improved function through decompression of symptomatic stenosis and correction of spinal imbalance [15].

A lateral approach to the degenerated disc space uniquely allows for release of the motion segment that typically becomes contracted with scoliosis. Release of the annulus helps to facilitate disc space mobilization and distraction, which in combination with the placement of a large laterally inserted interbody graft allows for restoration of disc height and may result in benefits of indirect neural decompression and improved lordosis.

The reduced morbidity afforded by the XLIF approach when compared with traditional surgical procedures makes this technique particularly appealing in the older patient population with adult degenerative scoliosis. It is important to note that the efficiency, safety, and speed afforded by the XLIF procedure should not tempt the surgeon to abandon established spine surgical principles.

The surgeon must always focus on appropriate neural decompression and achieving stability and spinal balance. In some cases, in the presence of fixed deformity, ACR with hyperlordotic cages provides a minimally invasive technique for the treatment of adult focal sagittal deformity. ACR can provide correction that is similar to three-column osteotomy focally, with reduction in morbidity to the patient [17–19]. As with all deformity surgical techniques, it is associated with a risk of major complications including vascular and neurologic injury and should be performed by surgeons who have had the required training and experience in deformity surgery and the XLIF approach.