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The preoperative evaluation provides the opportunity for assessment of patient, surgical, and anesthetic risks in order to formulate an appropriate anesthetic plan. This chapter presents a case study of a 27-year-old female, who presented with new onset of bilateral upper extremity weakness and sensory changes in neck and upper back pain. Co-morbidities associated with spinal disease range from acute traumatic spinal column instability or spinal shock to decreased cardiopulmonary function from chronic thoracic cage deformity. A comprehensive history and physical examination is a crucial component of preparation for complex spine surgery. The airway examination may be notable for limited cervical spine range of motion as well as instability increasing the risk of spinal cord injury. In an effort to achieve a successful outcome, preoperative evaluation should be thorough and consists of careful assessment of the risks associated with patient pathophysiology, anesthetic requirements, and the surgery itself.