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Abstract Introduction Demographic changes create an expansion of the elderly population segment of society. Demands of mobility and quality of life have increased in this age group over the last decades. A rising number of elderly patients suffering from degenerative “de novo” lumbar scoliosis (DLS) may be eligible for surgical options to treat their spinal deformities. Therefore, we compared the clinical and radiographic results of conservative and surgical treatment. Materials and methods During 1990–2003, 55 patients with DLS were treated and followed up for a minimum of 24 months. Group 1 patients (n = 26) underwent surgery (decompression and spondylodesis), group 2 patients (n = 29) declined surgery and received conservative treatment (analgesics, physiotherapy). Clinical data, theatre records and X-rays were analysed. All patients were contacted and 73.1% of group 1 and 75.8% of group 2 patients were clinically re-evaluated and received standing radiographs on average 4.8 and 3.8 years after the initial procedure or consultation, respectively. Results We found a significantly higher rate of spinal stenosis and degenerative spondylolisthesis in group 1 patients (P