Difficulty with mask ventilation is rare in patients with cervical spine disease, but flexion deformity may prevent mask application. Difficult intubation is most likely when the disease affects the cranio-cervical junction. Mouth opening ability and cranio-cervical movement are related. The flexible fibreoptic laryngoscope remains the instrument of choice in severe cervical disease. Post-operative airway obstruction is most likely after anterior surgery combined with posterior surgery, or anterior surgery lasting more than 5 hours. In extremis, one does what one does best, quickly, which is likely to be direct laryngoscopy and gum-elastic bougie or a supraglottic airway. Inhalational induction has been traditionally advised when the upper airway is obstructed. Neurological injury occurs during anaesthesia, both to peripheral nerves (the ulnar nerve being the most reported) and the neuraxis. The suspicion that airway management and direct laryngoscopy in particular can cause spinal cord injury (SCI) is deeply entrenched, but may be mythical.