Objective To investigate the current status and influencing factors of decision conflict regarding disease-modifying therapy in patients with spinal muscular atrophy (SMA), aiming to provide references for future interventions to improve the quality of patient decision-making. Methods Using convenience sampling, SMA patients admitted to the Department of Neurology, West China Hospital of Sichuan University between January 2023 and October 2025 were selected as study participants. Data were collected through questionnaires assessing general demographic characteristics, the Control Preferences Scale, and the Decisional Conflict Scale (DCS). Univariate analysis and multiple linear regression were employed to explore factors influencing patients’ decisional conflict. Results A total of 70 questionnaires were distributed, with 66 valid responses returned, resulting in an effective response rate of 94.3%. The standardized DCS score of SMA patients was 35.61±21.28, indicating moderate decisional conflict. Multiple linear regression analysis revealed that age [unstandardized partial regression coefficient (b)=?0.818, 95% confidence interval (?1.383, ?0.252), P=0.005] and residential location [b=?12.660, 95% confidence interval (?19.822, ?5.498), P=0.001] were independent influencing factors for decisional conflict, collectively explaining 35.0% of the variance (adjusted R2=0.318). Conclusions SMA patients exhibit moderate levels of disease-modifying therapy-related decisional conflict, with younger age and rural residence associated with more pronounced conflict. Clinical practice should focus on individual patient characteristics while enhancing decision aids and informational support to help reduce decisional uncertainty.