The complications of percutaneous pedicle screw fixation are similar to those of conventional open surgery. The key to percutaneous pedicle screw fixation is to master the entry point and the angle of entry, and to accurately screw the screw into the vertebral body via the pedicle. Due to the complex anatomy of the spine, incorrect needle insertion can lead to serious complications such as: ( 1) spinal cord and dural sac injury: the inward angle of the needle insertion is greater than 15°, which can easily cause sharp injury to the spinal cord and dural sac; ( 2) nerve root injury: the lateral and inferior direction of the pedicle screw, the screw is close to or partially through the intervertebral foramen, which may damage the nerve root; ( 3) needle injury to the internal organs or large blood vessels: as the operator (4) fracture of internal fixation: premature postoperative weight-bearing activities or quality of internal fixation can lead to fracture of internal fixation. Therefore, the following aspects should be noted when applying the RTS system to complete the percutaneous puncture pedicle screw internal fixation operation. (a) In preoperative planning and preparation, we must strictly grasp the indications for surgery, improve preoperative imaging, and complete 3D spiral CT reconstruction of the segment to be treated when available, so that the diameter and length of the selected screws can be predicted in preoperative planning through different imaging examinations, as well as to clarify whether the patient has an arch variation, so as to prevent multiple nail placement or nail placement failure during surgery. (b) It is emphasized that percutaneous pedicle screw placement must be done under fluoroscopic guidance, with standard frontal and lateral examinations to accurately locate the screw insertion point and monitor the screw insertion trajectory in order to avoid incorrect placement leading to nerve root injury. It is difficult to accurately determine the depth of the instrumentation during percutaneous operation, so the removal of the intervertebral disc and scraping of the cartilage end plate must be performed under c-arm x-ray monitoring, and attention should be paid to the scale on the operating instrumentation to avoid penetrating the intervertebral disc and damaging the abdominal organs; when tapping through the guidewire via the pedicle, the guidewire sometimes follows the tapping and penetrates the vertebral body, so the depth of the guidewire should be checked under fluoroscopy to avoid damage to the abdominal cavity after the guidewire (ii) The abdominal organs and blood vessels should be damaged after penetrating the vertebral body. (c) Intraoperative needle insertion and nail placement should be performed with attention to the angle of needle insertion and the position of the screw head. The ideal entry point of the pedicle is located at the junction of the tuberosity and the transverse process, and the direction of the needle should point to the inner wall of the cylinder, but should not be too close. Placing the screw head at the lateral edge of the lesser articular eminence prevents damage to the superior articular eminence and allows matching the tilt angle of the pedicle. There is a risk of injury to the spinal cord and dural sac if the nail entry point is too far inward. When the nail tip is near or beyond the midline of the spine during orthogonal projection, the screw may enter the infantile canal and the screw or guide pin should be withdrawn securely. If there is cerebrospinal fluid overflow, it means that the dura or spinal cord has been injured, fill the nail channel with gelatin sponge and bone wax, readjust the angle, and closely observe the motor sensation and sphincter function after surgery. (d) Patients with osteoporosis, the pedicle screw is difficult to anchor fixation, and it is very easy to loosen at this time. It is necessary to implant crushed bone or inject bone cement into the pedicle, and then perform screw fixation after pedicle strengthening. In addition, in patients with osteoporosis, the bone trabeculae per unit area are reduced, and there is a certain guiding error after opening the nail path, so we should strive for accurate pin placement and successful opening of the nail path at one time. (e) No additional external force should be given during intraoperative placement of the connecting rod. If the connecting rod cannot pass through the screw head smoothly and easily, the whole operation should be re-evaluated. During percutaneous pedicle screw fixation, the caudal ends of the two screws should be kept at the same level in the coronal and sagittal planes, otherwise it will lead to difficulties and misalignment of the rods; after the rods are installed, frontal and lateral fluoroscopy should be performed under the monitoring of the c-arm x-ray machine to ensure that the rods are installed correctly to avoid separation of the screws from the rods.