Multiple subpial transection (MST) is a palliative surgical disconnection procedure, which can be effective in the treatment of medically intractable epilepsy in select patient populations. It works by disrupting neuronal synchrony of epileptic activity in a critical circuit of neurons to stop the progression and expression of eileptiform activity and seizures. MST breaks up the epileptic neuronal synchrony among cortical columns disrupting the epileptic focus itself by the transection of the horizontal fibre system necessary to produce an epileptic spike. The procedure is occasionally curative and effectively treats epileptic seizures that cannot be helped by cortical resection. MST can be beneficial in the treatment of focal epilepsy arising from eloquent areas, refractory status epilepticus and localization-related epileptic encephalopathies. Significant outcome variability has been reported, in general showing good short-term seizure control when MST is performed by experienced groups but less successful outcomes in the long term.