Spontaneous spinal epidural hematoma (SSEH) is a rare but potentially devastating cause of acute spinal cord compression that requires prompt recognition and treatment. A 29-year-old man presented with sudden severe neck pain followed by rapidly progressive quadriparesis over 5 hours. He had no history of trauma, anticoagulant use, or known comorbidities. Neurologic examination showed weakness in all extremities, absent deep tendon reflexes, and a sensory level at T4. Cervical MRI revealed a posterior extradural collection from C4 to T1 causing severe cord compression, consistent with SSEH. Emergency surgery was performed within 8 hours of imaging via C3–C7 laminectomy and evacuation of the hematoma. Intraoperatively, two abnormal dilated dural vessels were identified and cauterized. Posterior instrumented stabilization sequentially performed due to extent of laminectomy. Neurologic improvement was evident by postoperative day 2, with near-complete recovery of motor strength. Diagnostic cerebral and spinal angiography performed on postoperative day 11, to evaluate a possible vascular etiology, was deemed unremarkable. However, the patient subsequently developed transient right-sided weakness, and cranial MRI showed multiple acute to subacute infarcts consistent with an embolic pattern. Further autoimmune, cardiac, and hematologic workup was unrevealing. After rehabilitation, the patient was discharged on postoperative day 36 with full motor recovery and normal sphincter function. At 5 months, he remained neurologically intact with stable implants. SSEH should be considered in patients with acute neck pain and rapidly progressive neurologic deficit, even in the absence of trauma or anticoagulant use. Early MRI and urgent decompression may result in excellent neurologic recovery. Careful consideration is warranted when pursuing invasive vascular workup after surgery, particularly when the diagnostic yield is uncertain.