Adult degenerative scoliosis patients present a challenge in trying to achieve the greatest benefit with the least amount of intervention. Tailoring the treatment to the severity of the symptoms and the deformity appears to be vital. Full understanding of the deformity in the coronal and sagittal planes as well as the neural impingement can guide one to the appropriate intervention. The first operation is critical in providing the best prognosis for the long term. Decompression alone is performed in patients with small magnitudes of scoliosis and minimal lateral listhesis. Decompression and posterior fusion with instrumentation is performed on patients with moderate deformity and lateral listhesis, but a balanced sagittal plane. The more technically challenging and larger operation, a combined anterior and posterior fusion with instrumentation, is reserved for those patients with not only moderate to severe curves, but also coronal and sagittal imbalance. Performing a smaller operation on these patients may not only be short-lived but may also start a series of higher-risk revisions. There is a distinct lack of studies identifying and documenting the risks, morbidity, and reoperation rates in this patient population as compared with other deformity groups. Treatment of degenerative scoliosis patients presents a challenge that is only growing larger in numbers with the aging population.