Spinal cord injury can be an expression of worsening of pre-existing myelopathy or associated to RLN injury, graft extrusion and hoarseness. It is described in literature as a fat graft migration causing cervical cord compression after dural tear repairs following anterior discectomy [9].

Anterior graft extrusion occurs in 2.1 % of cases and can be associated with RLN injury, spinal cord damage retropharyngeal abscess and consequent dysphagia. It may appear if there is no appropriate distraction in the disc space to hold the graft in a correct position. Approaching the disc space to have just the proper amount of body distraction is not always easy. Anterior graft extrusion may be avoided using the correct amount of interbody distraction to place the graft and modelling it to the containing site.

Posterior graft failure occurs in 0.3 % of cases, and it is associated with wire breakage, inferior screw pull-out or fracture of the graft with a fusion failure. This is common in rheumatoid patients [2, 6].

It may occur after ACD and it can be associated to dysphagia and dysphonia. In these cases, a quick reoperation with CSF fistula repair and a wide-spectrum antibiotic therapy is required [6].

They occur in 0.4 % of cases and often after corpectomies associated with ossification of the posterior longitudinal ligament (OPLL) or very severe spondylosis [2]. Fistula repair is generally required.

Meningitis is a rare but potentially life-threatening complication that could happen after cervical spine surgery. A high index of suspicion for meningitis should be maintained in patients with the clinical triad of fever, neck stiffness and consciousness disturbance after spinal surgery. Intraoperative incidental durotomy is the most important predictor. An early diagnosis, also through the imaging (Fig. 13.2) and appropriate antibiotic treatment, can lead to a good outcome [10].

Oesophagus perforation following anterior cervical spine surgery is a rare but potentially life-threatening lesion which can lead to death in 6–34 % of cases. Diagnosis is difficult and the treatment often delayed, resulting in cervical abscess, mediastinitis, septic shock and even death. The proper treatment should be surgical repair as soon as possible. Cervical oesophagus perforations are considered to be less critical than the intrathoracic and intra-abdominal ones due to slow formation of descending mediastinitis, but they may be still fatal in up to 16 % of cases.

It usually reveals within few hours after surgical procedure, but a case of delayed oesophageal perforation after cervical spine plating with a protruding screw is described. When a perforation is suspected (neck pain, dysphagia, odynophagia, fever, cervical emphysema), a CT scan with oral administration of a water-soluble contrast should be employed (Figs. 13.3, 13.4 and 13.5).

It is a rare but serious complication of anterolateral approach to the cervical spine with an incidence of 0–1.62 %. Proximity to the vertebral column and thin walls makes the upper digestive tract vulnerable to injury in cervical trauma. Clinical presentation and management are very similar to the oesophageal perforation.

A CT scan or MRI is necessary to seek the presence of any concurrent abscesses or vertebral stabilization failures (Fig. 13.6).

Osteomyelitis following cervical spine surgery is a serious complication that can overlap other scenarios like abscess and oesophageal and/or tracheo-oesophageal fistula [11].

CT scan is always needed for diagnosis (Figs. 13.7, 13.8 and 13.9); also bone scintigraphy may be helpful.