Background Multi-level spinal decompressions and fusions often require long anesthetic and operative times which may result in airway edema and prolonged post-operative intubation. Delayed extubation can lead to broncho-pulmonary infections and other complications. This study analyzed which factors correlated with the decision to delay extubation after multilevel spine surgery. Methods We reviewed the records of 289 patients having multilevel spine surgery lasting 8 hours or more in the prone position from 2006 to 2012. Variables hypothesized to affect the decision of the anesthesiologist to delay extubation at the end of the surgery were collected. These included preoperative factors (age, gender, ASA Class, history of obstructive sleep apnea, BMI, previous spine surgery, current cervical surgery, anterior in addition to posterior spine surgery, emergency surgery), and intraoperative factors (difficult intubation, number of surgical levels, case time, estimated blood loss, fluid and blood administration, attending handoff and resident handoff, and case end time). We also compared the incidence of pulmonary post-operative complications between patients extubated at the end of the case to patients who had a delayed extubation. Results 126 patients (44%) were kept intubated after multilevel spine surgery. Multiple linear regression analysis showed factors that correlated with prolonged intubation included age, ASA Class, procedure duration, extent of surgery, total crystalloid volume administered, total blood volume administered, and the case end time. Patients who had a delayed extubation had a threefold higher rate of post-operative pneumonia. Conclusions Our study finds that age, ASA class, procedure duration, extent of surgery, and total crystalloid and blood volume administered correlate with the decision to delay extubation in multilevel prone spine surgery. It also finds that the time that the case ends is an independent variable that correlates with the decision not to extubate at the end of a long multi-level spinal surgery. The incidence of post-operative pneumonia is higher in patients who had a delayed extubation after surgery.