Kyphosis is a difficult topic of spinal surgery, and its management contains many controversies. Surgical management needs consideration of different aspects of the kyphotic deformity such as neurological status, the presence of spinal cord compression, angle of the kyphosis, the quality of bone, and accompanying diseases. In case of significant cord compression and neurological compromise, anterior surgery should have the priority. However, in smooth-angled kyphosis and ankylosing spondylitis patients, deformity can easily be reduced by a posterior-only approach. Since they have no neurological deficits, and large spinal canals, most suitable patients for pedicle subtraction osteotomy are the patients with ankylosing spondylitis.In lumbar kyphosis one-level pedicle subtraction osteotomy (especially at L2 or L3 levels), in thoracic kyphosis multilevel osteotomies, and in cervicothoracic kyphosis an osteotomy at C7-T1 level should be preferred.Pedicle subtraction osteotomy is a technically demanding procedure that requires surgeons to perform meticulous technique and consider biomechanical issues to achieve satisfactory results and avoid complications. An attempt to correct the rigid fixed spinal deformity is a difficult task and requires the capability of a highly experienced spine surgeon. Although the physical outcome and patient satisfaction of surgical treatment is quite good, risks and complications should always be considered by both the physician and patient.