Surgical treatment of craniovertebral junction (CVJ) has undergone significant development, based on craniocervical dynamics, the site of encroachment and the stability of the craniovertebral junction and are increasingly employed the world over. Development of better instrumentations and intraoperative navigational systems has greatly contributed to this trend. Nevertheless, the treatment of patients with tumors in and around CVJ continues to be a challenge. A wide variety of congenital, developmental and acquired abnormalities along with tumors exist at the CVJ. These may occur singly or as more than one anomaly in the same individual and their pathology is extensive. They along with clinical presentation and a brief outline of management are discussed in “Craniovertebral Junction Abnormalities” chapter. The surgical approaches to CVJ may be subdivided into the posterior, lateral and anterior categories. Anterior approaches to bony pathologies and stabilization procedures are discussed in this chapter. The familiar standard posterior approaches are not discussed. Lateral approaches are discussed in chapter ‘skull base surgery’.