The use of spinal implants for spine fusion has been steadily increasing to avoid the risks of complications and donor site morbidity involved when using autologous bone. A variety of fusion cages are clinically available, with different shapes and chemical compositions. However, detailed information about their surface properties and the effects of such properties on osteogenesis is lacking in the literature. Here we evaluate the role of surface properties for spinal implant applications, covering some of the key biological processes that occur around an implant and focusing on the role of surface properties, specifically surface structure, on osseointegration, drawing examples from other implantology fields when required. Our findings revealed that surface properties such as micro-roughness and nanostructures can directly affect early cell behavior and long-term osseointegration. Micro-roughness has been well established in the literature to have a beneficial effect on osseointegration of implants. In the case of the role of nanostructures, the number of reports is increasing and most studies reveal a positive effect from the nanostructures alone and a synergistic effect when combined with micro-rough surfaces. Still, long-term clinical results are necessary to establish the full implications of surface nanomodifications.