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Introduction Trigeminal neuralgia remains a challenging disease with debilitating symptoms and variable efficacy in terms of treatment options. Microvascular decompression (MVD) with internal neurolysis (IN) is an alternative treatment that may provide patients benefit, but has limited understanding. We performed a systematic review of IN for the treatment of trigeminal neuralgia. Methods Studies from 2000 to 2021 that assessed IN in trigeminal neuralgia were aggregated and independently reviewed. Results A total of 520 patients in 12 studies were identified with 384 who underwent IN (mean age 53.8 years, range 46-61.4 years; mean follow-up 36.5 months). Preoperative symptoms were present for about 55.0 months before treatment and pain was predominantly in V2/3 (26.8%), followed by other distributions. An excellent to good outcome (Barrow Neurological Institute Pain Score [BNI-PS] I-II) was seen in 83.7% of patients (range 72-93.8%). Pain outcomes at 1 year were excellent in 58-78.4%, good or better in 77-93.75%, and fair or better in 80-93.75% of patients. On average facial numbness following IN was seen in 96% of patients however at follow-up remained in only 1.75-10%. Most remaining numbness was not significantly distressing to patients. Subgroup comparisons of IN vs. recurrent MVD, IN vs. radiofrequency ablation, the impact of IN during the absence of vascular compression, as well as IN with and without MVD were also evaluated. Conclusions IN represents a promising surgical intervention for trigeminal neuralgia in the absence of vascular compression or in potential cases of recurrence. Complications were limited in general, but require further study.