There is now no little doubt that decompressive craniectomy can reduce mortality following severe traumatic brain injury. However, the concern has always been that the reduction in mortality comes at the cost of an increase in the number of survivors with severe neurological disability. It was these concerns that prompted investigators to conduct a number of large multicenter randomized trials investigating surgical efficacy of the procedure. Whilst the results of these trials have confirmed the survival benefit that can be achieved this has only been achieved by increasing the number of survivors with severe disability and dependency. Whilst these findings may be difficult to accept they do not necessarily mean that use of the procedure should be abandoned but rather a more nuanced and patient-centered debate regarding the acceptability or otherwise of survival with severe disability is required. In addition, the use of long term observation outcome studies in combination accurate outcome prediction models in combination with may be used to highlight those patients likely to benefit from surgical decompression and facilitate discussions regarding realistic outcome expectations.