Objective To investigate the clinical efficacy of gradual controlled decompression in emergency surgery for severe brain trauma.Methods The clinical data of 50 patients with severe brain injury who underwent surgery at our hospital from 2012 to 2014 were retrospectively analyzed. The patients were divided into control group (n=21, conventional craniotomy and decompressive craniectomy) and treatment group (n=29, gradual controlled decompression) depending on what surgical procedure was used. The patients were followed up for 6 months. Poor prognosis was defined as a Glasgow Outcome Scale (GOS) score of 1 to 3 and favorable prognosis was defined as a GOS score of 4 to 5.Results In the control group, intraoperative acute encephalocele occurred in 7 patients, delayed ipsilateral brain hematoma in 8 patients, delayed contralateral brain hematoma or occipital epidural hematoma in 4 patients, and postoperative cerebral infarction in 6 patients. In the treatment group, intraoperative acute encephalocele occurred in 6 patients, delayed ipsilateral brain hematoma in 5 patients, delayed contralateral brain hematoma or occipital epidural hematoma in 3 patients, and postoperative cerebral infarction in 9 patients. Significant differences were found in the incidence of intraoperative acute encephalocele, delayed ipsilateral brain hematoma, and delayed contralateral brain hematoma or occipital epidural hematoma between the two groups (P<0.05). However, there was no significant difference in the incidence of postoperative cerebral infarction between the two groups (P >0.05). At the six-month follow-up, there were 11 patients with a GOS score of 1 to 3 and 10 patients with a GOS score of 4 to 5 in the control group, and 10 patients with a GOS score of 1 to 3 and 19 patients with a GOS score of 4 to 5 in the treatment group. Significant differences were noted in poor and favorable prognosis rates between the two groups (P<0.05).Conclusions Gradual controlled decompression in craniotomy can effectively reduce intraoperative and postoperative complications, decrease the rates of mortality and severe disabilities, and improve the prognosis for patients with severe brain trauma.