Degenerative spondylolisthesis is most often seen at the L4-5 level. The most common complaint is back pain, but the advent of leg symptoms, such as claudication and restless legs syndrome, is often the reason for seeking specialized medical attention. Conservative treatment usually suffices; extended bed rest is of little value. The 15% of patients who are surgical candidates are those with clinical signs and symptoms of cauda equina abnormality, progressive muscular weakness, or progressive incapacitating radicular pain or claudication. The author advocates pedicle-to-pedicle decompression with preservation of the articular facets as the essential operation. The indications for fusion have been debated, but recent prospective studies show improved outcomes after fusion. The risk of significant morbidity associated with laminectomy and fusion increases as a function of age and magnitude of operation; therefore, careful patient selection for surgical intervention is vital.