Background: Balloon kyphoplasty (BKP) is widely established as a minimally invasive and effective treatment for osteoporotic vertebral fractures (OVFs). While complications such as cement leakage are well-documented, spinal intradural hematomas- specifically subarachnoid hemorrhage (SSAH)-are exceedingly rare. We report a significant case of extensive SSAH causing delayed paraplegia following BKP, supplemented by a review of relevant literature to elucidate potential mechanisms and management strategies.

Case Description: A 76-year-old female underwent BKP at a local hospital for a T12 OVF. The immediate postoperative course appeared uneventful; however, late at night on the following day, she developed sudden, progressive paralysis in both lower extremities. She was emergently transferred to our university hospital for higher-level care. Spinal magnetic resonance imaging (MRI) revealed a massive  hematoma  extending  longitudinally  from T5 to L4, exerting severe compression on the spinal cord. Given the rapid neurological deterioration, emergency decompressive surgery was performed. Intraoperative findings confirmed the presence of a subarachnoid hemorrhage. The hematoma was successfully evacuated, and the spinal cord was decompressed. This case is notable for the extensive range of the hematoma compared to previously reported cases.

Discussion and Conclusions: A review of the literature suggests that intradural hemorrhages following vertebral augmentation are often associated with medial pedicle wall breaches or direct needle trauma to the dural sac and radicular vessels. The “delayed” onset of symptoms, as observed in this patient, is a critical clinical feature, potentially attributable to slow venous bleeding or a tamponade effect that eventually decompensates. This case underscores that despite the minimally invasive nature of BKP, catastrophic neurological complications can occur. Clinicians must maintain a high index of suspicion for spinal hematoma if a patient presents with new neurological deficits days after surgery. Rapid transfer to a tertiary center and immediate surgical decompression are essential for neurological salvage.