Objective: To investigate the role of large decompressive craniectomy LDC in the management of severe and very severe traumatic brain injury TBI and compare it with routine decompressive craniectomy RDC. Methods: The clinical data of 263 patients with severe TBI GCS≤8 treated by either LDC or RDC in our department were studied retrospectively in this article. One hundred and thirty-five patients with severe TBI, including 54 patients with very severe TBI GCS ≤ 5, underwent LDC LDC group. The other 128 patients with severe TBI, including 49 patients with very severe TBI, underwent RDC RDC group. The treatment outcome and postoperative complications of the two treatment methods were compared and analyzed in a 6-month follow-up period. Results: Ninety-six patients 71.7 % obtained satisfactory treatment outcome in the LDC group, while only 75 cases 58.6 % obtained satisfactory outcome in the RDC group P< 0.05. Moreover, the efficacy of LDC in treating very severe TBI was higher than that of RDC 63.0 % vs. 36.7 %, P < 0.01. The chance of reoperation due to refractory intracranial pressure ICP in the LDC group was significantly lower than that of the RDC group P < 0.05, while the incidences of delayed intracranial hematoma and subdural effusion were significantly higher than those of the RDC group P < 0.05. Conclusions: LDC is superior to RDC in improving the treatment outcome of severe TBI, especially the very severe ones. LDC can also efficiently reduce the chances of reoperation due to refractory ICP. However, it increases the incidences of delayed intracranial hematoma and contralateral subdural effusion.