Spinal surgery is an invasive procedure with the potential for serious complications. A low index of suspicion for exacerbation of a simple pneumothorax is imperative as intubation with positive pressure ventilation can cause progression to cardiovascular collapse. Novel methods of intraoperative diagnosis and treatment of pneumothorax in prone positioning such as ultrasound and lateral needle decompression are promising options to reduce the morbidity and mortality of posterior spinal surgery. Vital signs, pulmonary exam findings, portable radiography, and sonography equipment are all invaluable to the accurate diagnosis and early intervention for patients with pneumothoraces.