The surgical management of high-grade spondylolisthesis in adults remains challenging and controversial. Symptomatic patients often present with severe pain, neurologic deficits, or deformity. Although there are several surgical options, the decision to proceed with decompression and fusion depends on the patient's presenting symptoms and degree of instability. Posterolateral pedicle screw-rod fixation has improved rates of arthrodesis compared with traditional in situ fusions. Nevertheless, complications with operative management of high-grade spondylolisthesis can be severe.