This study evaluates the cost-effectiveness and outcomes of interspinous (ISD) and interlaminar devices (ILD) compared to decompression-alone surgery for treating degenerative lumbar pathologies. Analyzing 29 studies, it found that ISD/ILDs offer greater leg pain improvement at 3, 6, and 12 months but not at 2 years or last follow-up. Back pain improvement was significantly better with ISD/ILD only at 1 year. No significant differences were observed in SF-36 physical component scores or ZCQ symptom severity scores between the groups. However, decompression-alone showed better ZCQ physical function scores at 6 and 12 months. ODI and EQ-5D scores generally favored ISD/ILD, except at 6 months. Notably, ISD/ILDs were associated with higher reoperation rates and total care costs, without a significant difference in complications. The study concludes that while patient-reported outcomes (PROs) are similar for both treatments, the higher costs and reoperation rates of ISD/ILDs do not support their use as a cost-effective alternative to decompression-alone. This highlights the need for careful consideration of treatment options for degenerative lumbar pathologies, taking into account both effectiveness and economic factors.