This chapter explores the vascular complications associated with cervical spine surgery for both anterior and posterior approaches. Recognizing that cervical decompression and instrumentation are common procedures, it is important to understand the complications that can occur. Knowledge of the spine anatomy and potential anomalies allows for successful outcomes. Vertebral artery injury (VAI) is the most common vascular complication in both anterior and posterior approaches to the cervical spine. Although VAI can be life-threatening, early recognition and appropriate management more often than not will lead to acceptable outcomes.