Traumatic brain injury (TBI) is a significant contributing factor to injury-related deaths worldwide. Despite the medical and fiscal importance of this subject, guidelines for the surgical management of closed and penetrating TBI are largely based on Level III evidence. Furthermore, the results of a large, costly trial designed to further elucidate the role of decompressive craniectomy, an important surgical intervention in patients with severe TBI and medically-refractory intracranial hypertension, have limited applicability. In this review, we summarize the existing guidelines for the surgical management of TBI, present an overview of the underlying pathophysiologic principles and neurophysiologic consequences relating to decompressive hemicraniectomy, highlight the history, relevant studies, and outcomes pertaining to decompressive craniectomy for patients with severe TBI, and discuss some of the current controversies in the surgical management of traumatic brain injury. Despite the varied outcomes seen in the literature, DC is indeed an important intervention in the management of TBI, as it is highly effective at reducing ICP and thus, an important higher-treatment strategy for patients with medically-refractory intracranial hypertension. There will continue to be unresolved controversies regarding decisions pertaining to defining an "optimal" surgical candidate, specific timing, techniques, and post-operative management of TBI patients who undergo surgery. New guidelines for the surgical management of TBI are forthcoming. Regardless, for neurosurgeons involved in the care of individuals with TBI, understanding the pathophysiologic and neurophysiologic consequences of surgical interventions, and gaining an understanding of the extant literature is imperative.