The authors analysed brain stem auditory evoked potentials prospectively in 100 patients undergoing endoscopic microvascular decompression for management of hemifacial spasm over a period of two years. They then developed a scoring system based on electrophysiological events to predict the possibility of hearing loss postoperatively in these patients. After evaluating results of their scores, the authors suggest using perioperative and postoperative corticosteroids and nimodipine prophylactically in high-risk and medium-risk patients to preserve hearing function or at least minimise hearing loss. They also recommend customising approaches to these patients to prevent vasospasm and fixed cerebellar retraction which could lead to hearing impairment. As part of the study, the authors also found that high-speed drill use during craniotomy does not carry a significant risk of high frequency hearing loss. The incidence of hemifacial spasm is low and surgical management of this condition is rare. However, this scoring system is likely to be useful to neurosurgeons as well as neurotologists and electrophysiologists managing the patients in the operating room, and could also potentially predict risk of auditory system injury in acoustic neuroma as well as other posterior fossa surgeries.