Two approaches to the upper four cervical vertebrae are described in detail. For lesions of the atlanto-axial joint, the transoral route was used, whereas for those of the second, third, and fourth cervical vertebrae, the transthyrohyoid route was found to be the most direct. The two approaches are complementary. Twelve patients—five with atlanto-axial dislocation and seven with tuberculosis of the upper cervical vertebrae—were operated on. There were three deaths, which were deemed avoidable. These approaches, we hope, will open a whole new avenue to the treatment of afflictions of the upper cervical spine.