Background: Several pathologies that affect the craniovertebral junction (CVJ) can be treated by means of a microsurgical transoral approach (TOA) or, alternatively, with an endoscopic endonasal approach (EEA), which is potentially able to overcome some complications associated with the former approach. In this paper, after discussing updates in the recent literature, to which we add our own surgical experience, we critically analyse these procedures with the aim of demonstrating that the TOA still deserves to be considered a viable alternative and that, in selected cases, it can even be considered superior to the EEA. Methods: Our experience involves 25 anterior procedures in 24 paediatric and adult patients (18 TOA and seven EEA). The TOA group (13 male and five female patients) encompassed three tumours, three rheumatoid arthritis cases, one condylus tertius, three basilar invaginations, four impressio basilaris cases, one developmental anomaly of C0–C1, one os odontoideum, one posttraumatic C1–C2 compression and one C2 fracture. The EEA group (three male and four female patients, median age 39 years, operated on over a 7-year period) comprised four tumours, two impressio basilaris cases and one case of impressio basilaris with platybasia. Results: In the TOA group, all but one patient were discharged after posterior procedures within 2 weeks and improved or remained unchanged after surgery and during the follow-up period. No major complications occurred in the TOA group. In the EEA group, two patients who developed a cerebrospinal fluid (CSF) infection died, one from disease progression and the other from myocardial infarction. Conclusion: Our data, in agreement with those from previous reports on other series, suggest that no clear superiority of the EEA over the endoscopic TOA can be postulated so far; in fact, the EEA can produce complications similar to those observed with the TOA in CVJ surgery.