Purpose <p>The purpose of this study was to investigate the association between cannabis use disorder and adverse clinical events following anterior cervical discectomy and fusion (ACDF).</p> Methods <p>This propensity-matched retrospective cohort study was performed using a multi-institutional electronic medical record database. Adult patients undergoing single- and multi-level ACDF were included. The primary cohort of interest consisted of patients with a pre-operative diagnosis of cannabis use disorder. Controls were propensity matched with over three-hundred clinical variables. We excluded patients with prior spine surgery, spine neoplasms, trauma, osteomyelitis, and inflammatory conditions. Comparisons were made with Chi-squared and independent t-tests at thirty-days, ninety-days, one-year, and two-years.</p> Results <p>After propensity matching, there were 1,055 patients in the single-level and 1,003 patients in the multi-level cohorts. At thirty- and ninety-days, patients with cannabis use disorder undergoing single-level ACDF exhibited higher rates of mental health service engagement. However, at thirty-days, patients with cannabis use disorder demonstrated lower rates of opioid utilization in the multi-level cohort. At one- and two-year follow-up, there were similar rates of cervical spine reoperation, pseudoarthrosis, and adjacent segment disease between study cohorts.</p> Conclusion <p>Patients with cannabis use disorder demonstrated higher rates of mental health service engagement following single-level ACDF surgery and reduced rates of opioid consumption following multi-level ACDF surgery. These findings demonstrate increased short-term healthcare utilization among patients with cannabis use disorder following ACDF and underscore the need for prospective studies to clarify the clinical impact of cannabis on surgical outcomes.</p>