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A prospective randomized study was performed.To determine whether posterolateral fusion in patients with adult isthmic spondylolisthesis results in an improved outcome compared with an exercise program.In spondylolisthesis, satisfactory results have been reported with both surgical and conservative management. The evidence for treatment efficacy, however, is weak because prospective randomized studies are lacking.In this study, 111 patients were randomly allocated to an exercise program (n = 34) or posterolateral fusion with or without transpedicular fixation (n = 77). The inclusion criteria were lumbar isthmic spondylolisthesis of any grade, at least 1 year of low back pain or sciatica, and a severely restricted functional ability in individuals 18 to 55 years of age. Pain and functional disability were quantified before treatment and at 1- and 2-year follow-up assessments by visual analog scales (VAS).The 2-year follow-up rate was 93%. The functional outcome, as assessed by the Disability Rating Index and the pain reduction, was better in the surgically treated group than in the exercise group at both the 1- and 2-year follow-up assessments (P < 0.01). In the longitudinal analysis, the mean Disability Rating Index and pain improved in the surgical group (P < 0.0001). In the exercise group, the Disability Rating Index did not change at all, whereas the pain decreased slightly (P < 0.02).Surgical management of adult isthmic spondylolisthesis improves function and relieves pain more efficiently than an exercise program.