Surgical management of idiopathic scoliosis is based on the natural history of this spinal disorder and on the likelihood of developing a worsening deformity. Anterior surgical treatments continue to evolve and provide advantages over posterior procedures in specific instances. Open and thoracoscopic anterior approaches allow direct access to the anterior stabilizing structures of the spine, enable mobilization of a rigid deformity, and provide a large surface area for arthrodesis. Thoracoscopic procedures provide a more cosmetically appealing alternative to a large midline posterior or anterolateral thoracotomy scar. Although the indications and contraindications for anterior versus posterior surgical intervention (for thoracic and thoracolumbar curve patterns) have been defined to some degree, there remains appropriate flexibility in the decision-making process, allowing the surgeon to make an optimal recommendation for each patient based on surgeon experience and patient needs.