Posterior cervical approaches—including laminectomy, laminoplasty, posterior cervical fusion (PCF), and foraminotomy—are indispensable techniques for treating cervical myelopathy, radiculopathy, trauma, deformity, and tumors. Contemporary series and reviews report overall complication rates between approximately 10% and 30%, depending on patient comorbidity, procedure type, and fusion length, with higher rates in elderly, frail patients undergoing multilevel fusion. Acute neurological complications (most notably C5 palsy and spinal cord injury), infectious events, cerebrospinal fluid (CSF) leak, postoperative hematoma with airway compromise, pseudarthrosis, adjacent segment disease (ASD), and junctional kyphosis remain the main sources of morbidity.

This chapter synthesizes recent evidence (with emphasis on 2020–2023 literature) on the incidence, mechanisms, risk factors, prevention, and management of complications after posterior cervical surgery. We structure the discussion along a temporal axis—pre-operative risk stratification, intra-operative events, early postoperative complications, and late mechanical and alignment-related failures—and integrate anatomical considerations and surgical decision-making. Particular attention is given to the pathophysiology and management of C5 palsy, the role of intra-operative neuromonitoring (IONM) in preventing catastrophic cord injury, current concepts in surgical site infection (SSI) prevention, and strategies to mitigate pseudarthrosis and junctional problems in long posterior constructs. When combined with meticulous technique and protocolized perioperative care, these evidence-based strategies can substantially reduce complication rates and improve functional outcomes.