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A report on the use of recombinant activated factor VII in 4 patients who developed severe intractable bleeding and coagulopathy during spine surgery.To describe the role of recombinant activated factor VII for hemostasis during spine surgery.Recombinant activated factor VII is indicated for the treatment of bleeding episodes and the prevention of bleeding during surgery in patients with hemophilia with inhibitors. However, its use in adults undergoing spine surgery has not yet been reported.Four patients who underwent multilevel spine surgery through an anterior approach incurred massive bleeding and subsequently became coagulopathic. Standard hemostatic techniques were performed and blood products were transfused. Persistence of the bleeding prompted the use of recombinant activated factor VII.Treatment with recombinant activated factor VII led to an improvement in prothrombin time and partial thromboplastin time and brought about cessation in gross, nonsurgical bleeding intraoperatively. No clinically relevant thrombotic complications related to the drug were noted.Recombinant activated factor VII is promising as an adjunctive hemostatic agent for patients with perioperative bleeding problems during spine surgery. Efficacy is seen even at low doses.