Vertebral artery injuries during cervical spine surgery are rare, with a reported incidence of 0.3% to 0.5%. The vertebral artery enters the vertebral foramen most commonly at C6 and courses from anterior and lateral to medial and posterior with respect to the vertebral body up to C3. The vertebral artery has a more variable course in the atlantoaxial region. Careful assessment on preoperative imaging will identify common anomalies and help avoid a vertebral artery injury. If a vertebral artery injury occurs, rapid action is required to prevent exsanguination or catastrophic neurologic injury. Every attempt should be made to repair the vertebral artery because the contralateral artery may not provide sufficient blood flow in this spondylotic population. If repair is not possible and contralateral circulation is deemed adequate, endovascular coiling or primary ligation should be performed. Tamponade should be avoided as the definitive treatment because of well-known complications.