Safe and effective management of adult isthmic spondylolisthesis begins with a thorough patient evaluation to determine the precise etiology of the patient's complaints and includes appropriate spinal imaging. As most cases of isthmic spondylolisthesis are asymptomatic, it is critical to rule out other sources of pain. Treatment of adult isthmic spondylolisthesis requires a complete understanding of the deformity, which includes a global assessment of the patient's spine, consideration of pelvic parameters, and proper classification. Safe surgery for isthmic spondylolisthesis begins with comprehensive pre-operative planning as well as patient optimization for the operating room. Patients with adult isthmic spondylolisthesis, especially those with high-grade slips, present a variety of unique intra-operative challenges for the operating surgeon, many of which can be anticipated in advance. The most common perioperative complications include neurological injury and pseudarthrosis.