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ABSTRACT: Background: The aging spine often presents multifaceted surgical challenges for the surgeon because it can directly and indirectly impact a patient’s spinal alignment and quality of life. Elderly and osteoporotic patients are predisposed to progressive spinal deformities and potential neurologic compromise and surgical management can be difficult because these patients often present with greater frailty. Methods: This was a literature review of spinal alignment changes, preoperative considerations, and spinal alignment considerations for surgical strategies. Results: Many factors impact spinal alignment as we age including lumbar lordosis flexibility, hip flexion, deformity, and osteoporosis. Preoperative considerations are required to assess the patient’s overall health, bone mineral density, and osteoporosis medications. Careful radiographic assessment of the spinopelvic parameters using various classification/scoring systems provide the surgeon with goals for surgical treatment. An individualized surgical strategy can be planned for the patient including extent of surgery, surgical approach, extent of the constructs, fixation techniques, vertebral augmentation, ligamentous augmentation, and staging surgery. Conclusions: Surgical treatment should only be considered after a thorough assessment of the patient's health, deformity, bone quality and corresponding age matched alignment goals. An individualized treatment approach is often required to tackle the deformity and minimize the risk of hardware related complications and pseudarthrosis. Anabolic agents offer a promising benefit in this patient population by directly addressing and improving their bone quality and mineral density preoperatively and postoperatively.

Background: The aging spine often presents multifaceted surgical challenges for the surgeon because it can directly and indirectly impact a patient's spinal alignment and quality of life. Elderly and osteoporotic patients are predisposed to progressive spinal deformities and potential neurologic compromise and surgical management can be difficult because these patients often present with greater frailty., Methods: This was a literature review of spinal alignment changes, preoperative considerations, and spinal alignment considerations for surgical strategies., Results: Many factors impact spinal alignment as we age including lumbar lordosis flexibility, hip flexion, deformity, and osteoporosis. Preoperative considerations are required to assess the patient's overall health, bone mineral density, and osteoporosis medications. Careful radiographic assessment of the spinopelvic parameters using various classification/scoring systems provide the surgeon with goals for surgical treatment. An individualized surgical strategy can be planned for the patient including extent of surgery, surgical approach, extent of the constructs, fixation techniques, vertebral augmentation, ligamentous augmentation, and staging surgery., Conclusions: Surgical treatment should only be considered after a thorough assessment of the patient's health, deformity, bone quality and corresponding age matched alignment goals. An individualized treatment approach is often required to tackle the deformity and minimize the risk of hardware related complications and pseudarthrosis. Anabolic agents offer a promising benefit in this patient population by directly addressing and improving their bone quality and mineral density preoperatively and postoperatively., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)