Objective Open surgical access to the posterior fossa traditionally has been achieved by permanent bone removal and remains the mainstay of posterior fossa surgery, although craniotomy is an alternative. Considerable variation exists at both the national and international levels within a variety of neurologic and neurosurgical disciplines. In this study, we surveyed current practice patterns regarding preference of suboccipital craniotomy or craniectomy. Methods The membership directory of the American Academy of Neurological Surgeons was reviewed. SurveyMonkey was used to distribute the survey to members of the American Academy of Neurological Surgeons via a modified Dillman method for e-mail correspondence. Comparisons of frequency distributions, means, and medians, as well as multiple logistic regression were used to determine surgical preferences for craniotomy versus craniectomy. Results We received 1102 responses (19.6%). Overall, 542 (49.7%) respondents prefer craniotomy and 548 (50.3%) prefer craniectomy. Respondents who prefer craniotomy had completed a residency more recently than respondents who preferred craniectomy (15.9 vs. 21.1 years, P < 0.0001) and were more likely to practice outside of North America (P < 0.01). Some 81.4% of pediatric neurosurgeons prefer craniotomy compared with 43.6% of adult neurosurgeons (P < 0.0001). Craniotomy was most highly preferred for tumor resection and vascular malformation. Within the United States, there was significant variation in preference for craniotomy based on geographic region, with New England most commonly preferring craniotomy and the Mid-Atlantic region most commonly preferring craniectomy. Conclusions Our results show that preference for suboccipital craniotomy or craniectomy varies according to geographic location of practice, time since completing residency, and age of patient population.