Abstract
Severe rigid scoliosis (SRS) is a complex three-dimensional spinal deformity that often presents with limited curve flexibility, sagittal and coronal imbalance, and significant cardiopulmonary compromise. Management is challenging and controversial due to the complex interplay of factors involved in surgical decision-making. Key debates include the relative merits of posterior-only versus combined anterior-posterior approaches, optimal use and duration of preoperative traction, appropriate timing and staging of correction, and the selection and sequencing of osteotomy techniques based on curve characteristics. This narrative review outlines evidence-based best practices and critically appraises the ongoing controversies in the management of SRS. The review highlights the importance of a multidisciplinary, individualized approach that accounts for both the structural characteristics of the deformity and the patient's overall health.