Background <p>Iatrogenic vertebro-vertebral arteriovenous fistula (VVAVF) is an uncommon and potentially serious postoperative complication of spinal surgery. This case report highlights a rare occurrence of bilateral VVAVF after upper cervical spine fixation and the challenges in its diagnosis and management. The novelty of this case lies in its detailed description of the vascular anatomy involved, the surgical and endovascular interventions used and the successful treatment outcome.</p> Case presentation <p>A 64-year-old woman presented with bilateral VVAVF following upper cervical spine fixation surgery for an odontoid fracture. She had a history of high-altitude-fall injury and had undergone left frontotemporal craniotomy at another hospital. The patient developed active bleeding from the surgical site 1 week postoperatively. An emergency angiography revealed bilateral VVAVF at the V3 segment of the vertebral arteries. Endovascular treatment was performed that involved coiling of the left vertebral artery and embolisation of the right fistula. The patient’s condition improved substantially, and no recurrence of the fistula was observed on follow-up imaging.</p> Conclusion <p>This case highlights the critical need for early recognition and intervention in iatrogenic VVAVF and demonstrates the efficacy of endovascular management for this rare but serious complication. The findings emphasise the importance of meticulous surgical technique during upper cervical spine procedures and vigilant postoperative surveillance to mitigate vascular risks. Furthermore, this report underscores the value of advanced imaging modalities and endovascular interventions in addressing complex iatrogenic vascular injuries.</p>