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Background: Microvascular decompression (MVD) is the gold-standard surgical treatment for cranial nerve compression disorders, including trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN). This review synthesizes historical milestones, recent advances, and evolving techniques in MVD, with a primary focus on these conditions., Methods: A comprehensive literature review was conducted using databases such as PubMed, SpringerLink, Google Scholar, BioMed Central, Scopus, and ScienceDirect. Studies published between 1970 and 2024 were analyzed, emphasizing surgical techniques, clinical outcomes, and technological innovations in MVD. Articles addressing TN, HFS, GPN, and other cranial nerve disorders treated with MVD were selected for detailed evaluation., Results: MVD demonstrates high efficacy, with 80-90% of patients achieving immediate symptom relief. Nevertheless, 15-25% of patients experience symptom recurrence, though long-term outcomes remain favorable. Fully endoscopic MVD has shown potential for enhanced intraoperative visualization, particularly in complex anatomical regions; however, its impact on surgical precision and clinical outcomes is still under investigation. Moreover, innovations in visualization technologies, including three-dimensional exoscopic systems and artificial intelligence-assisted surgery, continue to improve procedural safety and outcomes. Despite these advancements, complications such as hearing loss (1-2%) and cerebrospinal fluid leakage (2-4%) persist, highlighting the need for continuous refinement of techniques., Conclusions: MVD is evolving with the integration of cutting-edge technologies, resulting in improved clinical outcomes and reduced complication rates. Emerging innovations such as robotic-assisted MVD and gene therapies for cranial nerve disorders, including TN and GPN, promise even greater efficacy and precision. However, further research is necessary to standardize surgical protocols and address disparities in healthcare systems globally., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)