Heat a large pot or Dutch oven over medium heat. Add olive oil and onion, cooking for 2–3 minutes until softened.
Add sausage and cook until browned, breaking apart as it cooks. Drain excess fat if needed.
Stir in garlic, Italian seasoning, and tomato paste; cook for 1 minute.
Add crushed tomatoes, carrots, stock, and salt. Bring to a boil, then reduce to a simmer. Cover and cook for approximately 15 minutes, or until carrots are tender.
Add tortellini and cook according to package instructions until tender.
Remove from heat and stir in spinach, cream, and red wine vinegar. Adjust seasoning and serve.