STUDY DESIGN: Cross sectional survey. OBJECTIVES: To compare pediatric spine surgeons' relative rankings of the importance of surgical considerations, and their reliability of ratings of the physical deformity of patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Adolescents' appearance is a factor in surgical decision-making. Although the reliability of the Cobb angle has been extensively studied, less attention has been directed toward the reliability of surgeons' assessment of physical appearance. METHODS: Five surgeons ranked the relative importance of 13 surgical considerations. While viewing clinical photographs of 40 patients, surgeons rated the following: shoulder blades, shoulders, waist asymmetry, and the "overall appearance" of the back. RESULTS: "Severity of deformity" was consistently ranked the most important surgical consideration. Surgeons, however, varied widely in their reliability of their ratings of physical appearance: shoulder blades (kappa = 0.34), shoulders (kappa = 0.22), waist (kappa = 0.24), and overall appearance (kappa = 0.40). CONCLUSION: Because patients' physical appearance is an important element of surgical decision-making, differences among surgeons could be contributing to inconsistent recommendations.