Lumbar degenerative spondylolisthesis is a common reason for spine surgery in the elderly. Surgery is usually performed with decompression of the stenotic level of the lumbar spine. In the last decades, instrumented fusion has often been added to decompression. However, recent research from randomized trials showed that fusion may not be necessary in most patients with lumbar degenerative spondylolisthesis. Systematic reviews and meta-analyses concluded evidence for decompression alone as the first choice of treatment for degenerative spondylolisthesis. Midline-preserving, microsurgical decompression is commonly utilized in patients with degenerative spondylolisthesis. Decompression can be performed with a unilateral approach for over-the-top decompression or a bilateral approach for bilateral decompression. Tube-assisted approaches and endoscopic decompression are other surgical alternatives that have gained popularity in the last years.