Pregnancy-related aggressive vertebral hemangioma presenting with radiculopathy: illustrative case.

backgroundAggressive vertebral hemangiomas are uncommon vascular spinal lesions that may enlarge during pregnancy due to hormonal and hemodynamic changes. Elevated estrogen and progesterone levels, increased blood volume, and venous congestion can lead to rapid lesion expansion and epidural extension, causing neurological deficits. Although rare, these lesions should be considered in pregnant or postpartum women presenting with back or radicular pain. OBSERVATIONS: A 30-year-old woman with epilepsy controlled by lamotrigine developed progressive low back and right leg pain during late pregnancy, worsening postpartum. MRI revealed an aggressive L4 vertebral hemangioma with epidural extension compressing the thecal sac and right L4 nerve root. The patient underwent L4 laminectomy, excision of the epidural component, and vertebroplasty. Persistent bleeding after initial posterior cement injection required a second injection through the left pedicle to fill the superior vertebral body, followed by fibrin glue application. She was mobilized on the 1st postoperative day, and her symptoms resolved completely. LESSONS: Pregnancy-related aggressive vertebral hemangioma should be suspected in women with new-onset neurological symptoms during pregnancy or postpartum. Early diagnosis, multidisciplinary planning, and timely decompression with vertebroplasty yield excellent neurological recovery and functional outcomes. https://thejns.org/doi/10.3171/CASE25860.