Study DesignRetrospective cohort.ObjectivesTo assess the incidence, time to presentation, and independent risk factors for retropharyngeal hematoma causing airway obstruction following anterior cervical discectomy and fusion (ACDF).MethodsThe PearlDiver national database was queried for patients who underwent one- to four-level ACDF. Patients who underwent concomitant posterior fusion or had surgical indications related to malignancy, trauma, or infection were excluded. Patients were stratified based on the development of a retropharyngeal hematoma causing airway obstruction within 7 days. Descriptive statistics assessed differences in patient demographics and comorbidities. Univariable and multivariable regression analyses identified independent predictors.ResultsAmong 430,542 patients, 140 (0.03%) developed postoperative retropharyngeal hematoma leading to acute airway obstruction. A significant proportion of patients presented within 1 day of surgery (45 patients, 32.14%), with 23 (16.43%) on day zero and 22 (15.71%) on day 1. Notably, 40.71% of cases occurred after discharge. Independent predictors included ossified posterior longitudinal ligament (OPLL) (aOR: 8.07, < 0.001), male gender (aOR: 2.30, < 0.001), hypertension (aOR: 1.67, < 0.05), viral hepatitis (aOR: 1.57, < 0.05), and comorbidity index (aOR: 1.14, < 0.001).ConclusionThis study identified a 0.03% incidence of retropharyngeal hematoma leading to acute airway obstruction and several independent predictors, including comorbidity index, male gender, hypertension, viral hepatitis, and OPLL. Surgeons should consider overnight admission for observation in patients with these risk factors, as a significant proportion of hematomas present within 1 day of surgery.