Hemifacial spasm (HFS) is a common cranial nerve disorder characterized by involuntary twitching of facial muscles primarily starting in the orbicularis oculi and gradually affecting other facial expression muscles on the same side. The exact cause of HFS is not yet fully understood, but it is widely accepted that vascular compression at the root exit zone (REZ) of the facial nerve leads to demyelination. Microvascular decompression (MVD) is considered to be the gold-standard treatment for primary HFS, aiming to alleviate the compression and restore normal nerve function. Advancements in neuroimaging, neuroanatomy, electrophysiology, technical equipment, and surgical understanding have led to improved functional protection of neurovascular structures during MVD surgery, enhancing the safety and effectiveness of HFS-MVD. This article aims to present the recent clinical research progress in HFS-MVD including the understanding of HFS pathogenesis, preoperative evaluation, electrophysiological monitoring techniques, application of surgical techniques, and postoperative regression analysis.