Background Data: Surgical fixation of the cervicothoracic junction (CTJ) is difficult due to the complex anatomy and biomechanical properties of this area. Several important vascular, visceral, and soft tissue structures make access to this region challenging; therefore, knowledge of these structures is essential for decompression and fixation. The posterior approach is commonly used in many diseases of the spine but is inadequate when targeting the anterior spinal elements; thus, it can result in a higher complication rate and can disturb spinal stability. For these reasons, different posterolateral and anterior approaches have been developed. Study Design: Systematic review of the literature Purpose: To compare these different anterior and posterior surgical approaches to the CTJ, indicating pathologies, outcomes, and complications. Patients and Methods: This review was done using the standard methodology outlined in the Cochrane Handbook and reported the findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. An initial search has been carried out using PubMed, Embase, Cochrane Library, Ovid, Scopus, and Google Scholar databases using the following keywords; cervicothoracic junction, C7/T4, surgical fixation; posterior approach; anterior approach. Results: Our systematic review yielded 12 studies with 419 patients that met our inclusion criteria, including seven studies using the anterior and five posterior approaches for treating different spinal pathologies. In this review, most patients with traumatic and neoplastic injuries were treated through the anterior approach, and those with degenerative and infectious diseases were treated through the posterior one. Assessment of the reported neurological status change pre- and postoperatively showed a significant difference between the anterior and posterior groups favoring the anterior one, and the rate of complications of the posterior approach was higher than that in the anterior approach. Conclusion: The data in this review may demonstrate both the effectiveness and safety of the anterior approach compared to the posterior one. These data indicate that patients who underwent the anterior approach have a higher incidence of improvement in their neurological functions and that complications in the anterior group are relatively less than those in the posterior one.(2021ESJ231)