To analyze the efficacy and safety of three different microvascular decompression (MVD) techniques in treating patients with hemifacial spasm (HFS). Methods: A total of 114 HFS patients were randomly divided into three groups, with 38 patients in each group: the full-course decompression group, the central segment decompression group, and the monitored decompression group. All three groups underwent MVD. In the full-course decompression group, full-course decompression of the facial nerve was performed during surgery. In the central segment decompression group, only the central segment of the facial nerve was decompressed. In the monitored decompression group, decompression of the central segment of the facial nerve was carried out under intraoperative neurophysiological monitoring. The therapeutic effects, surgical-related indicators, facial spasm severity before and after surgery, facial nerve function [evaluated using the House-Brackmann (H-B) grading system and the Sunnybrook Facial Grading System (SFGS)], auditory nerve function [assessed by latency, interpeak latency, and amplitude of brainstem auditory evoked potentials (BAEP)], complication rates, and recurrence rates were compared among the three groups. Results: The total effective rates in the monitored decompression group and the central segment decompression group were higher than that in the full-course decompression group (P<0.05). The monitored decompression group had shorter operation time, less intraoperative blood loss, and shorter hospital stay compared to the central segment decompression group, which in turn had better outcomes than the full-course decompression group (P<0.05). At 3 months and 12 months postoperatively, the monitored decompression group showed superior improvement in facial spasm severity compared to the central segment and full-course decompression groups (P<0.05). At 3 months and 12 months postoperatively, the H-B grades in the monitored decompression group were lower than those in the central segment decompression group, which were lower than those in the full-course decompression group. The SFGS scores in the monitored decompression group were higher than those in the central segment decompression group, which were higher than those in the full-course decompression group (P<0.05). At 3 months and 12 months postoperatively, the BAEP latency, interpeak latency, and amplitude in the monitored decompression group were better than those in the central segment decompression group, which were better than those in the full-course decompression group (P<0.05). The complication rates in the monitored decompression group and the central segment decompression group were lower than that in the full-course decompression group (P<0.05). There was no significant difference in recurrence rates among the three groups (P>0.05). Conclusion: Performing central segment decompression of the facial nerve during MVD for HFS can optimize the surgical process, facilitate disease recovery, enhance clinical efficacy, and improve patient prognosis. The effect is particularly more pronounced when decompression is performed under neurophysiological monitoring.