Craniocervical instability is a surgical disease that presents the treating surgeon with a complex combination of characteristics including spinal cord and brain stem compression, distorted anatomy, and difficult biomechanics. Treatment most often requires a combination of neural decompression, fusion, and instrumentation. Over the last several decades, a number of surgical techniques for instrumentation of the craniocervical junction have been developed that allow both greater flexibility and enhanced safety for patients with this condition. Development of an optimal craniocervical instrumentation construct requires careful consideration of preoperative and intraoperative goals, available options, and the applicability of each option for any given patient. Only when each of these things has been considered can the likelihood of a positive outcome be maximized.