Vertebral hemangiomas (VHs) are common benign tumors that are mostly asymptomatic. Only 0.9-1.2% of invasive VHs have neurological symptoms due to compression of the spinal cord, nerve roots, or both due to bony swelling, cortical erosion, extension into the spinal canal, impaired blood flow, epidural hemorrhage. In addition, pyramidal hemangiomas can lead to serious complications, such as pathological fractures of the spine. This article reports a case of multiple thoracic hemangioma involving the spinous process with a pathological fracture of the pyramidal segment of the next segment, and summarizes the published literature on pyramidal hemangioma involving the spinous process.