Postpartum hemorrhagic vertebral hemangioma with pathological vertebral fracture: A case report highlighting spinal instability as a potential mechanical cofactor

Background: Aggressive vertebral hemangiomas (VHs) rarely cause fracture or epidural hemorrhage. Pregnancy- related hemodynamic changes may promote progression, whereas the role of instability is poorly defined. Case Description: A 30-year-old female presented 2-week postpartum with severe mechanical thoracolumbar pain and mild right leg weakness. Imaging showed an aggressive T12 VH with >50% collapse, kyphosis, posterior epidural hemorrhagic extension, and marked canal compromise. The retrospective Spinal Instability Neoplastic Score was 15/18. After preoperative embolization, a T12 and superior L1 laminectomy/decompression was performed, and the hematoma was removed. Gross T11-L1 instability was noted intraoperatively, thus warranting simultaneous T10-L2 fusion plus open T12 cement augmentation. Postoperatively, strength normalized within 1 week, and 2 years later, she remained pain-free and neurologically intact without radiological progression or recurrence. Conclusion: In this postpartum case, pathological collapse and instability accompanied hemorrhagic progression of an aggressive VH. When instability is evident, simultaneous stabilization should be considered along with decompression.