Background context <p>Endometriosis is a chronic inflammatory disease characterized by endometrial-like tissue outside the uterus, affecting approximately 10% of women of reproductive age. While typically confined to the pelvis, lesions may occur in extra-pelvic sites, including the vertebral spine. Vertebral-spinal endometriosis (VSE) is extremely rare and often presents with nonspecific pain or neurological symptoms, making diagnosis and treatment challenging.</p> Purpose <p>To comprehensively review the clinical presentations, diagnostic approaches, and treatment outcomes of VSE, to improve clinical awareness and guide management strategies in spine practice.</p> Study design <p>Comprehensive review of published case reports, conducted in accordance with PRISMA 2020 guidelines.</p> Patient sample <p>Fourteen female patients, aged 20–50 years, with histologically or radiologically confirmed VSE reported in published case reports between 1968 and 2025.</p> Outcome measures <p>Primary outcomes included symptom resolution or improvement following treatment. Secondary measures included type and location of spinal lesions, diagnostic modalities, histological confirmation, and recurrence rates.</p> Methods <p>A comprehensive search of PubMed, Google Scholar, and the Cochrane Library identified eligible case reports. Two reviewers screened studies, extracted data, and resolved disagreements by consensus. Findings were synthesized narratively, and data are presented descriptively as counts, proportions, and simple summary statistics.</p> Results <p>Of 188 records screened, 14 met the inclusion criteria. Patients were reproductive-age women (mean age 37.9 ± 8.2 years). A documented prior diagnosis of pelvic endometriosis was present in 4 of 14 cases, although eight patients (8/14 57.1%) had symptoms related to menstrual correlation. The most frequent presenting symptoms were radicular pain (10/14, 71.4%), back or lumbosacral pain (9/14, 64.2%), and urinary or bladder dysfunction (5/14, 35.7%). Lesions predominantly involved the lumbar spine (11/14, 78.5%), with rare thoracic (1/14, 7.1%) and sacral foraminal (2/14, 14.3%) cases. MRI was the primary diagnostic modality (13/14, 92.9%). Histopathology confirmed endometriosis in 13 of 14 cases. Treatments included spinal decompression or lesion excision alone (6/14, 42.9%), hormonal therapy alone (3/14, 21.4%), and combined surgery plus hormonal therapy (5/14, 35.7%). Overall, 8 of 14 patients (57.1%) became symptom-free or nearly symptom-free, and 6 of 14 (42.9%) had partial but clinically meaningful improvement. Recurrent spinal endometriosis was documented in 2 of 14 cases over follow-up periods ranging from 6 to 30 months.</p> Conclusions <p>Vertebral-spinal endometriosis presents with diverse symptoms and variable treatment responses. MRI and histopathology are essential for diagnosis. The small evidence base precludes definitive conclusions regarding whether lesion location or treatment modality predicts outcomes.</p>