Venous thromboembolism is a life-threatening adverse event in spine patients and presents difficult decisions for the surgeon and patient. Prophylactic protocols have been established to prevent the occurrence of venous thromboembolism and its sequelae, including venous occlusion, edema, postthrombotic syndrome, and death. Despite the known benefits of prophylaxis, some surgeons choose not to use it because of concerns over increased bleeding complications and possible iatrogenic neurologic injury. Although mechanical prophylaxis remains an important element in venous thromboembolism prevention, low-molecular-weight heparin is better than other pharmacologic therapies in decreasing the incidence of major events.