A prospective, multicenter, propensity-matched cohort assessment compared the outcomes of patients with at least a 2 year follow-up with adult spinal deformity (ASD) that were treated with operative versus non-operative measures (97 in each group). The patients displayed at least one of the following: scoliosis >= to 20 deg, sagittal vertical axis >= 5 cm, pelvic tilt >= 25 deg, and thoracic kyphosis >= 60 deg. Health related quality of life (HRQOL) was assessed with the Oswestry Disability Index (ODI), the Scoliosis Research Society-22r (SRS-22r) the Short Form-36 version 2 (SF-36) and the numeric rating scale for back and leg pain (NRS). Despite patients in the surgical arm having a lower pre-treatment HRQOL in all measures compared to the non-operative arm (p<0.001), at 2 year follow-up, patients in the surgical arm displayed a significantly higher HRQOL for all measures (p<0.001) except for the SF-36 mental component score (p=0.04). However, 71.5% experienced >= 1 complication. While it is apparent that this intervention involves a high degree of complexity with the associated complications, patients who undergo surgery experience a significant improvement in quality of life. Moreover, patients who are managed non-operatively will typically not improve.