Microvascular decompression is currently the most effective treatment for trigeminal neuralgia, facial spasm and glossopharyngeal neuralgia because of its minimal trauma, high safety and cure rate, and low complication rate, especially the complete preservation of vascular and nerve function. The operator’s experience and precise microscopic technique have an important impact on improving the cure rate, reducing the recurrence of postoperative symptoms and reducing the occurrence of surgical complications. Preoperative diagnosis and differential diagnosis, intraoperative exposure of the nerve root, identification of the responsible vessel, and selection and placement of the cushion are key to the surgical outcome, with special emphasis on freeing the responsible vessel and pushing it away from the nerve root, and placing decompression tampons between the vessel and the brainstem; trigeminal nerve decompression should ensure that the portion of the nerve root to Meckel’s foramen is fully released in the axial phase. Intraoperative avoidance of facial and auditory nerve and fine penetrating vascular injuries, as well as intraoperative brainstem auditory evoked potential monitoring, can reduce the occurrence of complications such as hearing impairment.