The use of spinal osteotomies has made it possible to orthopaedically correct severe spinal deformities that were previously uncorrectable. With the development of advanced posterior surgical techniques, good orthopedic results can be achieved with a single posterior approach, which can shorten operative time and reduce intraoperative position changes. Although most orthopedic procedures can be accomplished through a single posterior approach, some deformity correction procedures require a combined anterior and posterior approach. With the development of surgical techniques and neuromonitoring, correction of severe spinal deformities has become possible and relatively safe. Extensive anatomical knowledge, careful preoperative surgical planning, specialized tools and endosseous plants are essential to the success of an orthopedic procedure. The decision to proceed with surgical treatment is the first one to be made. After the surgical decision is made, a detailed surgical plan helps to ensure a smooth operation. The main surgical plan should be developed preoperatively, and some of the key ideas for the plan need to be discussed with the patient and his or her family. For example, if the patient does not want to face a larger surgery for a better shape, then the surgeon should present the patient with what can be achieved with a smaller release maneuver; conversely, if good orthosis is the patient’s primary claim and the team can safely complete the surgery, then a three-column osteotomy is feasible when a smaller osteotomy will not achieve the desired goal. Determination of deformity flexibility The use of the least risky operation to achieve the orthopedic goal is critical to ensure that orthopedic spine surgery is performed safely. If posterior multisegmental release can achieve similar orthopedic results as triple column osteotomy, then triple column osteotomy is not necessary. Determining the flexibility of the deformity is often difficult, and if the deformity is found to be less flexible than expected intraoperatively (softer or stiffer), the surgical plan may need to be adjusted intraoperatively. The height of the intervertebral space, the opening of the lateral intervertebral space on a Bending film, and the reduction in flexion in the patient’s prone position or on a traction film can all be very helpful in determining spinal flexibility. New 3D printing technology can provide surgeons with a preoperative model of the patient’s spine to better prepare for critical surgical steps.