The presence of osteoporosis in patients who are candidates for spinal surgery can affect preoperative planning. These patients may not need instrumentation for a successful surgical result, but if use of instrumentation is indicated because of instability or deformity, certain principles should be observed. These include using multiple sites of fixation, accepting lesser degrees of deformity correction, and avoiding ending the instrumentation within kyphotic segments. Advances in perioperative medical management, as well as improved instrumentation systems, may also contribute to improving patient outcomes.