Objective To investigate the application effect of stepped decompression under intracranial pressure monitoring and conventional large bone flap decompression in the treatment of severe craniocerebral trauma. Methods The clinical data of 60 patients with severe craniocerebral trauma treated in Fengcheng Hospital of Fengxian District from January 2020 to December 2021 were analyzed retrospectively. According to different treatment methods, they were divided into the control group (30 cases) and the observation group (30 cases). The control group was treated with conventional large bone flap decompression, and the observation group was treated with stepped decompression under intracranial pressure monitoring. The operation condition, CT sellar temporal muscle thickness, the change of intracranial pressure, Glasgow coma scale (GCS) score, Mannitol application condition and the incidence of complications were compared between the two groups. Results The initial decompression time and ICU hospitalization time in the observation group were shorter than those in the control group, the amount of intraoperative bleeding in the observation group was less than that in the control group, the differences were statistically significant (P＜0.05). There were no significant differences in the CT sellar temporal muscle thickness and intracranial pressure between the two groups (P＞0.05). The CT sellar temporal muscle thickness in the two groups were higher than those before operation, and the intracranial pressure in the two groups were lower than those before operation, the differences were statistically significant (P＜0.05).The CT sellar temporal muscle thickness and intracranial pressure in the observation group were lower than those in the control group, the differences were statistically significant (P＜0.05). There was no significant difference in the GCS score before operation between the two groups (P＞0.05).The GCS scores of the two groups after operation were higher than those before operation, and the differences were statistically significant (P＜0.05). The GCS score of the observation group after operation was higher than that of the control group, the difference was statistically significant (P＜0.05). The application time of mannitol in the observation group was shorter than that in the control group, and the application dose of Mannitol in the observation group was lower than that in the control group, and the differences were statistically significant (P＜0.05). The total incidence of complications in the observation group was lower than that in the control group, the difference was statistically significant (P＜0.05). Conclusion Step decompression under intracranial pressure monitoring is more effective in the treatment of severe craniocerebral trauma. It can accelerate the decrease of intracranial pressure, reduce the application dose of Mannitol, promote the recovery of GCS score, shorten the length of stay in ICU and reduce the risk of complications.