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Expectation Versus Reality: Exploring Decisional Regret in Minimally Invasive Lumbar Spine Surgery. BACKGROUND AND OBJECTIVES: Unrealistic or unmet expectations can contribute to lower satisfaction and decisional regret (DR), particularly as shared decision-making becomes more central in elective spine care. Understanding these dynamics in minimally invasive lumbar decompression may guide strategies to optimize preoperative counseling and patient-centered outcomes. Our study aims to evaluate the correlation between patient expectation-actuality differences and DR following minimally invasive lumbar decompression surgery and to identify other patient-reported outcomes associated with DR. METHODS: This prospective cohort study included adults undergoing elective one-level or two-level minimally invasive lumbar decompression. Patients completed preoperative Musculoskeletal Outcomes Data Evaluation and Management Systems (MODEMS) expectation surveys and postoperative MODEMS actuality surveys at 3 and 6 months, along with the Decisional Regret Scale at both time points. Expectation-outcome mismatch was calculated for each MODEMS domain. Predictors of DR were assessed using univariate linear regression, with significance set at P < .05. RESULTS: Among 104 patients (mean age 64.9 years, 54.5% male), 60% reported no regret and 11% high regret at 3 months, compared with 61% no regret and 6% high regret at 6 months. Across both time points, DR was strongly associated with greater expectation-outcome mismatch. In univariate regression, mismatch in pain relief, daily activity, exercise, sleep, return-to-work, and disability prevention significantly predicted higher regret, with pain relief showing the largest effect. Demographic and clinical factors, including age, sex, comorbidity burden, and preoperative disability, were not associated with regret. MODEMS mismatch remained the most consistent predictor at both follow-ups. CONCLUSION: DR in minimally invasive lumbar decompression is strongly linked to expectation-actuality differences and reduced satisfaction, with pain relief, activity, and exercise emerging as key drivers. These findings highlight the importance of refining tools to assess expectations and identify unmet needs to reduce regret and improve patient-reported outcomes.