To systematically evaluate the oncologic and functional outcomes of combined anterior–posterior (AP) versus posterior-only (P) surgical approaches for the management of lumbosacral chordomas. A systematic review and meta-analysis was conducted according to PRISMA guidelines, searching PubMed, Embase, and Scopus through July 2025. Comparative studies reporting resection margins, local recurrence, survival, and complications were included. Data were pooled using random-effects models to calculate odds ratios (OR) and incidence rate ratios (IRR). Ten retrospective studies comprising 134 patients (71 AP, 63 P) were included. The AP cohort contained a significantly higher proportion of complex, high-level (S1–S2) tumors (p = 0.008). There were no statistically significant differences in 3-, 5-, or 10-year overall survival between approaches. However, the AP approach was associated with significantly higher odds of local recurrence (OR 3.50, 95% CI 1.63–7.55; p = 0.001) and a trend toward higher rates of contaminated margins (p = 0.059). Additionally, the AP approach demonstrated a significantly higher risk of total postoperative complications (IRR 2.27, 95% CI 1.42–3.64). Posterior-only resection is associated with lower local recurrence rates and a more favorable safety profile compared to combined approaches. However, the higher recurrence rate in the AP cohort is likely attributable to confounding by indication, as AP strategies were preferentially utilized for extensive high-sacral lesions. Despite disparate recurrence rates, long-term survival remains comparable, suggesting that surgical selection should be individualized based on tumor topography and the necessity for ventral release.