BACKGROUND: Severe traumatic brain injury (TBI) presents significant management challenges, with decompressive surgery being a critical intervention. This review aimed to evaluate the efficacy of controlled decompression versus conventional decompression techniques in managing severe TBI across multiple outcomes. METHODS: A comprehensive search of electronic databases (PubMed Central, SCOPUS, EMBASE, Chinese national knowledge infrastructure, Cochrane trial registry, WHO trials platform) was conducted to identify studies comparing controlled decompression with conventional methods in severe TBI patients. Pooled analysis was done using a random-effects model with inverse variance technique. RESULTS: Thirteen studies were included. Controlled decompression significantly reduced mortality (OR 0.498, 95% CI 0.321-0.773, p = 0.002), postoperative complications (OR 0.283, 95%CI: 0.205-0.390, p <
0.0001), cerebral infarction (OR 0.488, 95% CI 0.293-0.813, p = 0.006), and brain swelling (OR 0.409, 95% CI 0.252-0.661, p <
0.0001). Improvements were also observed in favorable outcomes (OR 1.822, 95% CI 1.211-2.740, p = 0.004), prognosis (OR 2.488, 95%CI 1.292-4.792, p = 0.006), and total effective rate (OR 6.549, 95% CI 1.852-23.153, p = 0.004). Minimal heterogeneities were found across outcomes, although the quality of evidence was downgraded to low due to higher risk of bias across most studies. CONCLUSIONS: Controlled decompression significantly improves outcomes in severe TBI patients compared to conventional methods. Future high-quality, multicenter randomized controlled trials are recommended to confirm these findings and guide clinical practice.