Microvascular decompression has been now accepted worldwide as a reasonable treatment for trigeminal neuralgia, yet, as a functional operation in the cerebellopontine angle, this process may be risky and the postoperative outcomes might not be good enough sometimes. To assess the effectiveness and safety of microvascular decompression for treatment of trigeminal neuralgia, we conducted a systematic review. Using the keywords “trigeminal neuralgia”, “microvascular decompression”, or “neurovascular conflict”, manuscripts published in English-language journals and indexed in PubMed between January 1, 2000 and June 1, 2013 on the treatment of trigeminal neuralgia (TN) with microvascular decompression were considered for this study. The success and complications were analyzed. The success in this investigation was defined as complete pain free. Continuous outcomes were summarized using means or medians, and dichotomous outcomes were presented as percentage associated with 95% confidence interval. Twenty-six papers with 6,847 patients were finally enrolled in this review. Among them, the male-to-female ratio was 1:1.4, the left-to-right ratio was 1:1.6, and the pain was located in the innervation of V3 and/or V2 in most of the cases with only 2.3% (0.1–4.7) of V1 exclusively. The average age at surgery was 60.9 years (52.5–64.1) with TN symptoms duration of 24.7 months (6.1–42.1) before microvascular decompression (MVD). Operative findings confirmed the superior cerebellar artery, anterior inferior cerebellar artery, posterior inferior cerebellar artery, and multiple vascular contacts (including veins) as the most common sources of nerve compression. The average follow-up duration was 35.8 months (26.2–56.6). The success rate was 83.5% (79.6–89.1). Complications included incisional infection in 1.3% (0.1–2.5), facial palsy 2.9% (0.5–6.2), facial numbness 9.1% (1.3–19.6), cerebrospinal fluid leak 1.6% (0.7–2.5), and hearing deficit 1.9% (0.2–3.9). The postoperative mortality was 0.1% (0.02–0.2). Accordingly, MVD is the most effective treatment for patients with trigeminal neuralgia. An immediate pain free can be achieved by an experienced neurosurgeon with good knowledge of the regional anatomy. To avoid complications, each single step of the process cannot be overemphasized.