Early surgical observations during microvascular decompression (MVD) procedures have contributed to our knowledge and theories regarding the pathophysiology of trigeminal neuralgia. This procedure represents the only therapy that directly addresses the presumed etiology of the disease and is associated with the longest duration of pain relief. Once thought to represent a major operation with significant risks and rate of mortality, MVD is now performed routinely and safely worldwide because of advances in anesthesia, monitoring, and microsurgical technique. Modern imaging now provides accurate preoperative assessment of the trigeminal nerve, which should increase surgical success rates and limit failures or complications.