Background <p>Spontaneous spinal epidural hematoma (SSEH) is an exceedingly rare clinical entity often associated with neurological deficits, for which surgical intervention remains the mainstay of treatment. We report a case successfully managed through complete conservative therapy.</p> Case presentation <p>A 59-year-old Chinese male with a medical history of hypertension, chronic smoking, and alcohol use presented to our institution with acute-onset low back pain accompanied by bilateral lower limb weakness and hypoesthesia persisting for 30&#xa0;min. Diagnostic imaging (CT and MRI) revealed a thoracolumbar epidural hematoma (T11-L1 distribution). Contrary to conventional surgical management paradigms, we implemented a comprehensive conservative management protocol. Remarkably, complete resolution of symptoms and spontaneous hematoma absorption were achieved within 20 days.</p> Conclusion <p>This case demonstrates that select SSEH cases may achieve favorable outcomes through conservative management without surgical decompression.</p>