The authors discuss the sitting, supine, and lithotomy positions in spine surgery. Indications for each position are discussed, as are advantages and drawbacks of each. The sitting position is utilized in posterior cervical and some thoracic procedures. It allows excellent visualization and diverts blood away from the field. However, it is associated with the major complication of air embolism and can be difficult for teams to use. The supine position is widely utilized and straightforward in its application. It is used for anterior approaches to the spine. Improper supine positioning can lead to pressure ulcers and neuropathies. The lithotomy position is rarely used in neurosurgery, but useful in the setting of anterior lumbar surgery in the patient with spondyloptosis or a very steep sacral inclination. It can, however, be associated with neuropathies and the dread complication of compartment syndrome.