Abstract: Objective To compare the effectiveness of microscope-guided vs neuroendoscop-guided microvascular decompression in the facial nerve for vertebral artery associated hemifacial spasm.Methods A total of 54 patients who underwent microvascular decompression due to vertebral artery associated hemifacial spasm in the First Affiliated Hospital of Nanjing Medical University from January 2018 to December 2020 were enrolled and their clinical data were retrospectively analyzed.The postoperative complications and effectiveness of microscope-guided vs neuroendoscop-guided microvascular decompression in the facial nerve were compared.Results Among 30 patients in the microscope-guided surgery group, 18 cases were cured, 11 cases were delayed cured, and 1 case was ineffective, where the effective rate was 96.67%, the delayed cure rate was 36.67%, and the ineffective rate was 3.33%, with an incidence of surgery-related complication of 3.33%. Among the 24 patients in the neuroendoscope-guided surgery group, 21 cases were cured, and 3 cases were delayed cured, without ineffective cases, where the surgical effective rate was 100%, the delayed cure rate was 12.50%, and the ineffective rate was 0, with an incidence of postoperative complications of 4.17%. There was no significant difference in the cure rate between the two groups, but the delayed cure rate in the microscope-guided surgery group was significantly higher than that in the neuroendoscope-guided surgery group(P<0.05). There was no statistical difference in postoperative complications between the two groups.Conclusions Neuroendoscope-guided microvascular decompression is a safe and effective surgical method for patients with vertebral artery associated hemifacial spasm, which can reduce the delayed cure rate to certain extent.