Introduction: Degenerative lumbar spondylolisthesis affects approximately 10% of adults over 40. Although decompression has been the treatment of choice, some surgeons note possible instability development after decompression alone (D). Previous studies show that decompression with fusion (DF) has similar complication rates but is better at preventing slip progression and reducing pain. However, others stated the additional instrumentation does not result in superior functional outcomes and has higher costs and complication rates. This study aims to provide an objective, two-arm comparison of the two treatments using systematic review and meta-analysis. Methods:The study design was a systematic review and meta-analysis of relevant randomized controlled trials and nonrandomized comparative studies. A systematic search was conducted from April 2021 to September 2021 to identify relevant studies using PubMed, Google Scholar, EMBASE, and Cochrane databases based on PRISMA guidelines.Results: This systematic review included 8 studies (6.669 patients); 7 (6.569 patients) were included in the meta-analysis, with a follow-up period of up to 143 months. The most commonly affected level was L4-5, with females being more affected than males. Visual Analog Scale improvement on back pain was significantly better in DF group (Heterogeneity, I 2 = 32%; WMD −0.72; 95% Confidence Interval (CI), −1.35 to −0.08; P = 0.03), as well as postoperative back pain (I 2 = 96%; WMD 0.87; 95% CI, 0.19 to 1.55; P = 0.01). The leg pain, Oswestry Disability Index (ODI), satisfaction rate, complication rate, and revision rate were comparable between the two procedures.Conclusions: Current systematic review and meta-analysis proved that DF is better than D in terms of back pain improvement, and the two procedures are comparable in terms of leg pain, ODI, satisfaction rate, complication rate, and revision rate.