The purpose of this study was to document the medical and surgical complications of anterior spine surgery in children and to identify risk factors for complications. A retrospective chart review was conducted of 599 anterior procedures (24 anterior only, 300 staged anterior/posterior, 175 combined anterior/posterior procedures) performed between 1967 and 1991. Major complications occurred in 7.5% of procedures and minor complications in 33%. Risk factors for major complications were age > 14 years, male gender, kyphotic curve type, curve sizes > 100 degrees, vital capacity < 40% of predicted, and use of thoracotomy. Risk factors for minor complications were age > 14 years, curves > 100 degrees, vital capacity < 40% of predicted, and use of a staged procedure. Multivariate analyses of risk factors identified age > 14 years and curves > 100 degrees as the most significant risk factors for major complications and age > 14 years for minor complications. We concluded that anterior spinal surgery can be performed in children with an acceptable level of risk and that referral for surgery before 14 years of age and before the curve size progresses will significantly reduce the risk of complications.