I. Overview Vertebral metastatic tumor, vertebral hemangioma and vertebral myeloma mostly cause local bone destruction, resulting in different degrees of local pain and neurological deficits, seriously affecting patients’ quality of life and survival. Age-related osteoporosis is one of the main causes of thoracolumbar back pain, and patients are prone to fracture, with the vertebral body being the most prone to fracture. Traditional treatments are conservative treatments such as bed rest for 3-6 months, oral painkillers and calcium. Some patients can get relief from pain symptoms, but prolonged bed rest is likely to lead to the aggravation of osteoporosis and bedsores and other complications. In 1984, Galibert, a French radiologist, first used percutaneous vertebral body puncture to inject bone cement for the treatment of vertebral hemangioma to obtain significant pain relief, thus pioneering percutaneous vertebroplasty (PVP). Subsequently, this technique has been gradually applied to patients with vertebral metastatic tumors, vertebral myeloma, and osteoporotic vertebral compression fracture, and has quickly gained the recognition of physicians from various disciplines including radiology, orthopedics, and neurosurgery due to its good efficacy and low complication rate, and it has become the most important treatment for the above diseases. The application of percutaneous kyphoplasty (PKP) for osteoporotic vertebral compression fractures also has comparable pain-relieving effects to those of percutaneous vertebroplasty (PVP), and the basic operation of PKP is the same as that of percutaneous vertebroplasty (PVP), except that the perforation channel needs to be dilated after successful puncture, and an 8 G working trocar is ultimately inserted, and then a specialized balloon is inserted into the diseased vertebra. PKP is mainly used for osteoporotic vertebral compression fracture, and is less commonly used for benign and malignant tumors of the vertebral body. Currently, interventional radiologists advocate the less invasive percutaneous vertebroplasty (PVP). Second, the indications for percutaneous vertebroplasty (PVP) 1, osteoporosis vertebral compression fracture: (1) once a clear diagnosis of osteoporotic vertebral fresh compression fracture, no need to wait for conservative treatment, can be performed as early as possible percutaneous vertebroplasty (PVP); (2) osteoporosis vertebral compression fracture by conservative treatment for more than 6 weeks of back pain is still obvious, confirmed by MRI and CT of vertebral fracture has not yet healed; (3) S. S. Vertebralis, a vertebral fracture of the vertebral body, is not healed; (4) S. Vertebralis, a vertebral fracture of the vertebral body is not healed. (3) Schmorl’s nodes (limited collapse of the upper and lower endplates of the vertebral body, resulting in the nucleus pulposus of the intervertebral disc detaching into the vertebral body and sclerosis of the margins, which is a common cause of chronic low back pain), and exclude the thoracolumbar and back pain caused by other reasons. (2) Vertebral metastasis: (1) vertebral metastatic tumor causing local intolerable pain, which needs to be maintained by analgesics, or with pathological compression fracture of vertebra; (2) asymptomatic osteolytic vertebral metastatic tumor, feasible percutaneous vertebroplasty (PVP) treatment. 3. Vertebral myeloma: the principle of selection of indications is the same as that of vertebral metastatic tumor. 4, Vertebral hemangioma: applicable to progressive vertebral hemangioma, with the same indications as metastatic vertebral tumor. Contraindications to percutaneous vertebroplasty (PVP) 1. Absolute contraindications: (1) vertebral tuberculosis, bacterial infection; (2) severe coagulation dysfunction, which cannot be corrected. Relative contraindications: (1) extensive bone destruction at the posterior margin of the vertebral body, large range of incomplete; (2) vertebral body compression more than 75%, no puncture access is expected; (3) vertebral body metastatic tumor is osteogenic and combined with obvious osteosclerosis of the vertebral arch root, it is expected to be difficult to puncture; (4) coagulation dysfunction, bleeding tendency. Preoperative preparation 1, bone cement: percutaneous vertebroplasty (PVP) is usually used low viscosity bone cement, due to bone cement powder and liquid mixing and polymerization and solidification in a relatively short period of time, the surgeon must be familiar with the physical and chemical properties of bone cement. 2, instruments and equipment: (1) image-oriented equipment: c-arm x-ray machine is the necessary imaging equipment to ensure intraoperative two-way positioning; (2) puncture needles: bone piercing needle with a core, thoracic and lumbar vertebrae with 11-13 G, cervical vertebrae with 14-15 G, are disposable; (3) syringes: the commonly used bone cement syringes are all disposable; (4) surgical stainless steel hammer: surgical hammer hammer to advance the needle. (4) Surgical stainless steel hammer: the surgical hammer is easy to control the direction, size and depth of needle insertion, and the safety is good; (5) Commonly used interventional sterile surgical bag. 3, the operator to prepare: the operator should be trained to obtain the appropriate qualifications; the operator’s unit should have surgical and emergency department support. The physician should define the vertebrae to be treated according to the CT film in order to determine the side of the needle. The preoperative conversation should be detailed and must be understood by the patient and his family, and sign the informed consent form. The content of the conversation includes: (1) general complications: allergic reaction to bone cement; intraoperative death induced by cardiovascular and cerebrovascular lesions; anesthesia accidents; the need for prone position during the operation, which leads to thoracic and abdominal compression can be caused by asphyxiation and death. (2) Complications related to percutaneous vertebroplasty (PVP): vertebral puncture damage to blood vessels resulting in hemorrhage and death; puncture damage to nerves, or leakage of bone cement compression of nerves resulting in radiating pain or even paralysis of the corresponding nerves, which requires surgery; leakage of bone cement into the spinal canal resulting in incontinence or retention caused by pressure on the dural sac; embolism of the pulmonary artery; unsatisfactory results; recurrent fracture of the vertebral body; vertebral body and intervertebral disk infection; pneumothorax; pneumoconus; and other complications. Pneumothorax; surgical failure and other unforeseen accidents. 4.Patient preparation: perfect all laboratory tests, including preoperative blood routine, coagulation time, liver and kidney function, electrolytes, erythrocyte sedimentation rate and ultrasensitive C-reactive protein. Take spinal MRI, CT and front and side x-ray film, chest x-ray film, etc. MRI can accurately identify the bone. MRI can accurately identify new and old fractures of osteoporotic vertebrae, show the site of vertebral fracture and the degree of compression, and can comprehensively and clearly show the number, site, degree of compression and whether the dural sac is compressed by the tumor metastasis vertebrae. CT examination can know whether the bone cortex at the edge of compressed vertebral body is intact or not, whether there are free bone fragments in the vertebral canal or not, can judge the type of vertebral body metastatic tumor (osteolysis, osteogenic or mixed), can judge whether the pedicle root is intact or not, and the degree of destruction of bone cortex at the posterior edge of the vertebral body, and can observe the anatomical structure of the penetration pathway and so on. Radiographs can see the compression and collapse pattern of osteoporotic vertebrae, but it is difficult to identify fresh and old compression, so it is difficult to accurately determine the painful vertebrae and sites of osteoporotic multiple vertebral compression, which is easy to cause underdiagnosis and under-treatment. For vertebral tumors, radiographs can only show lesions when vertebral destruction and compression collapse are obvious. Therefore, MRI and CT are the imaging methods that must be performed before percutaneous vertebroplasty (PVP), while spinal frontal and lateral radiographs can only be used as a reference for localization. Intravenous access is established for patients, and sedation is available half an hour before surgery. For patients with severe pain and difficulty in turning over and lying down, analgesic treatment can be used 10-20 min before the operation, or contact anesthesiologists to help with intraoperative pain relief in order to facilitate the safe completion of percutaneous vertebroplasty (PVP) surgery. Thoracolumbar puncture is often performed in the prone position with the needle inserted through the pedicle, while the cervical spine is performed in the supine position with the needle inserted through the anterolateral side. Cardiac and pulse oximetry monitoring should be performed throughout the procedure. 1, thoracic and lumbar percutaneous vertebroplasty (PVP) operation: at present, most physicians operate under the supervision of c-arm x-ray machine, and there are two positioning and puncture monitoring methods to choose from, and method one is more commonly used at present. The operation steps of method 1 are as follows: (1) the patient takes the prone position, and routinely disinfects and spreads the towel; (2) under the posterior anterior fluoroscopy, make both sides of the pedicles symmetrically displayed, and select the outer edge of the outer margin of the pedicles as the puncture point of the outer 1-2 cm; (3) use 2% lidocaine in the skin of the puncture point toward the direction of the pedicles to do the puncture channel of the whole soft-tissue infiltration anesthesia; (4) puncture the needle to the posterior margin of the pedicles. posterior margin of the pedicle, and then do two-way fluoroscopy, in lateral fluoroscopy will be puncture needle direction as far as possible to adjust to the lesion of the vertebral body in the same line, lateral fluoroscopy with a surgical hammer to tap the puncture needle into the pedicle root, repeated a number of times in both directions to locate, when the head end of the needle arrived at the posterior margin of the vertebral body, orthopedic fluoroscopy shows that the needle just crossing the inner edge of the pedicle root, which is the more desirable state of the penetration, the lateral fluoroscopy will be the needle to tap the needle to advance to the anterior 1/3 of the vertebral body. The tip of the puncture needle is located in the center of the vertebral body; (5) Make bone cement and draw it into the bone cement syringe; (6) When the bone cement is viscous, inject it slowly into the vertebral body under lateral fluoroscopy, and stop the injection if any obvious leakage is found; (7) When the puncture needle is withdrawn, put in the core of the needle to push the bone cement remaining in the cannula of the needle into the vertebral body, and then rotate the needle backwards, and local pressure at the puncture point should be applied. Backward, the puncture point localized compression for 3~5 min after bandaging the end of the operation. The specific steps of method 2 are as follows: 1. Angle the x-ray tube to the sagittal plane and to the pedicle at an angle of 10-15 degrees, so that the target side of the vertebral arch is displayed in the center of the vertebral body, and then insert the puncture needle in a straight line with the vertebral arch and the x-ray tube, i.e., under fluoroscopy, the puncture needle will become a point-like shadow, so that the point-like projection will always be kept in the vertebral arch projections, to make sure that the puncture needle has not broken through the vertebral arch. 2. Cervical percutaneous vertebroplasty (PVP) operation: Because the vertebral arch root is short and thin, the transverse process originates from the lateral and posterior part of the vertebral body where it connects with the vertebral arch root, and the transverse foramen in the center has the vertebral artery and vertebral vein passing through it, therefore, generally, the transverse approach via the lateral and posterior part of the vertebral arch is not used in cervical percutaneous vertebroplasty (PVP). The transverse anterior approach below the c3 vertebrae and the transoral approach to the c1 and C2 vertebrae are used for puncture and needle insertion. The procedure is as follows: (1) the patient lies supine on the operating table, with the neck and shoulders elevated, the head and neck extended posteriorly and deflected to the contralateral side, and the head placed on a suspended cloth frame; (2) routine neck disinfection and laying of a towel; (3) fluoroscopy to determine the cervical vertebrae to be punctured, touching the carotid arteries, and determining the puncture point parallel to the selected vertebral body between the medial side of the carotid artery and the trachea, and using 1% to 2% lidocaine on the aligned vertebral body to do the puncture pathway for total soft-tissue infiltration Anesthesia; (4) puncture the target vertebral body along the carotid artery and trachea gap with the puncture needle, penetration into the vertebral body, positive and lateral fluoroscopy and photographic confirmation of the puncture needle head end is located in the center of the vertebral body or the anterior middle 1/3 of the junction, then the puncture is successful; (5) Cement mixing, injection and withdrawal of puncture needle method as described above. (1) Before operation of cervical percutaneous vertebroplasty (PVP), one should be familiar with the anatomy of the safe puncture channel in the neck. Since the carotid artery and jugular vein are easily displaced, the carotid artery should be touched and pushed outward during the operation, and it should not be loosened until the puncture is successful. (2)The puncture point of thoracic spine should be selected 1~2 cm lateral to the surface projection of the vertebral arch root, and should not be too far away, otherwise it may penetrate into the pleural cavity and cause pneumothorax; if thoracic rib joints are used for puncture, the operation should be gentle for osteoporotic people to avoid causing rib fracture and new pain. (3) Transpedicular puncture should avoid damaging the cortex of the medial side of the pedicle to prevent injury to the nerve root. (4) Whether vertebral venography is necessary after successful vertebral body puncture is still controversial, and many physicians believe that vertebral venography does not help to prevent cement leakage, but rather increases the cost and radiation time. (5) The judgment of improper puncture is mostly made when the puncture needle enters into the middle and posterior 1/3 of the pedicle, at this time, the needle can be withdrawn and re-punctured, and the tip of the puncture needle is mostly in the anterior middle third of the vertebral body when injecting, and it is very unlikely that the bone cement will leak out backward along the first cortical puncture hole. In order to prevent leakage, the cement should be reinjected in the middle of the cement thickening period. (6) The amount of bone cement injected: in order to get the exact effect, the general amount of cervical vertebrae 1-2 ml, thoracic vertebrae 3-5 ml, lumbar vertebrae 4-6 ml. 60%～65% of the patients with compression fracture can be filled up from the contralateral side only by injecting from the unilateral side, and if the injection from one side is unsatisfactory, it is feasible to inject from both sides. Postoperative treatment: lie supine for 2-6 h, monitor vital signs 1 time/h within 6 h, and get out of bed for light activities after stabilization. The patient can be discharged from the hospital after 1-3 d of postoperative observation. If after 1-3 d of back pain relief after percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fracture, there is recurrence of severe pain in the thoracolumbar back, which is aggravated by activity and can be alleviated by lying down, there should be a high suspicion of new vertebral fracture, and MRI is preferred, and if there is other new vertebral fracture, percutaneous vertebroplasty (PVP) can be performed immediately. Postoperative treatment should also be carried out accordingly for the primary disease. The clinical efficacy evaluation of percutaneous vertebroplasty (PVP) focuses on pain relief and prevention of vertebral collapse. 1, pain efficacy evaluation: the WHO standard, the degree of relief is divided into 4 levels: (1) complete relief (CR): pain symptoms completely disappeared, life is completely self-care; (2) partial relief (PR): pain relief is obvious, occasional symptoms, no need to use oral painkillers, most of the life can be self-care; (3) slight relief (MR): pain symptoms, the use of oral painkillers can stop pain, part of life can be self-care; (3) mild relief (MR): pain symptoms, the use of oral painkillers can stop pain, part of the life can be self-care; (4) the use of oral painkillers can stop pain, part of life can be self-care; (5) pain relief (MR): pain symptoms, pain relief, pain relief, pain relief. (4) Non-Relief (NR): no pain relief, oral painkillers can not completely stop the pain, rely on strong painkillers. CR and PR are considered effective. Currently also commonly used pain grading method (visual analogue scale, VAS), that is, image analogical scoring method for pain efficacy evaluation, with VAS score 0-10 points to indicate the degree of pain, 0 points for no pain, 10 points for severe pain. Reduction of VAS by more than 3 points after treatment was considered effective. Significant remission (CR): VAS score 0-3; partial remission (PR): VAS score 4-6; no remission (NR): VAS score >7 or difference in VAS score before and after treatment <3. < p=""> Percutaneous vertebroplasty (PVP) has a better pain relief effect on tumors and osteoporotic fractures, with most patients having an effect from the immediate postoperative period to 72 h (36 h on average), with a pain relief rate of 72% to 85% for metastatic tumors and myeloma and 78% to 96% for osteoporotic compression fractures. The metastatic tumor of vertebral body should be treated with percutaneous vertebroplasty (PVP) for 3~4 weeks and then chemotherapy or radiotherapy should be used to further control the tumor and prolong the survival of patients. 2.Preventing vertebral body collapse: the effect is difficult to evaluate, according to limited literature reports to strengthen the vertebral body for the purpose of the recent results of patients did not appear vertebral body collapse, but at present there is no prospective, randomized bulk study can make a definite conclusion on this role. Because osteoporosis is a systemic disease, there is a risk of wan new compression fractures in adjacent or distant vertebrae after percutaneous vertebroplasty (PVP). VIII. Complications and treatment 1. Complications related to puncture: (1) Puncture injury to the nerve root: the puncture needle penetrates the medial margin of the pedicle through the lateral saphenous fossa and injures the nerve root resulting in symptoms of nerve root damage and irritation, which is rare in the clinic. (2) Intravertebral hematoma: uncommon, mostly caused by the use of thicker puncture needles to tear the dura mater or the dural venous plexus leading to intravertebral hematoma, and may even cause acute progressive spinal cord or dural sac compression, requiring emergency surgical decompression. Clinical manifestations of postoperative nerve root compression progressive aggravation, and even the spinal cord compression level and the following sensory and muscle strength to carry on the decline, line MRI examination can be earlier found in the spinal canal hematoma. (3) Pedicle root dissection: uncommon. The risk of intravertebral hematoma and cement leakage into the spinal canal can be increased by dissection of the pedicle. (4) Rib fracture: rib fractures can occur in severely osteoporotic individuals treated with thoracic percutaneous vertebroplasty (PVP), but this complication is rare. Theoretically the use of surgical hammer tapping to advance the puncture needle could prevent these fractures. Complications related to cement injection: Common sites of cement leakage include the dural sac outside the spinal canal, the nerve root canal, the paravertebral soft tissues, the adjacent intervertebral discs and the paravertebral venous plexus. Most have no serious clinical consequences. The incidence of leakage varies greatly, the leakage rate of early percutaneous vertebroplasty (PVP) for vertebral tumors is higher, and in recent years, the incidence of leakage of percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fracture has been significantly reduced to l%~6%. (1) Leakage of bone cement along the needle channel: Bone cement can occasionally leak backward into the soft tissues around the vertebral body along the needle channel, mostly without clinical symptoms. When the leakage of the needle channel to the subcutaneous pain caused by the more serious, need to be cut to remove the leakage of bone cement. (2) Leakage of bone cement into paravertebral tissues: the bone cement leaks into the soft tissues around the vertebral body through the fracture gap of vertebral cortex or the osteolytic damage area of tumor, mostly asymptomatic, no special treatment is needed. (3) Leakage of bone cement into the vertebral canal and intervertebral foramen: it is easy to occur in the case of extensive destruction of the bone cortex at the posterior margin of the vertebral body. If more bone cement leaks into the vertebral canal, it may lead to acute compression and obstruction of the vertebral canal. Common clinical symptoms after leakage from the spinal canal and intervertebral foramina include: ①Neurogenic pain: caused by leakage of bone cement into the foraminal veins or intervertebral foramina, which mainly occurs in percutaneous vertebroplasty (PVP) for the treatment of vertebral malignant tumors, with a much higher incidence than in other indications. Oral non-steroidal anti-inflammatory drugs and other treatments can usually be relieved, a very small number of patients with nerve root pain is very stubborn, difficult to relieve with drug therapy, and requires surgical removal of the leakage into the neural foramen of the cement has been polymerized and hardened in order to cure. ② Vertebral canal compression: Leakage of bone cement into the vertebral canal can compress the spinal cord or cauda equina leading to paralysis, the incidence is low. When the leakage in the vertebral canal shows obvious symptoms of spinal cord compression, early surgery is needed to remove the cement that has been polymerized and hardened in the vertebral canal in order to avoid paralysis. (4) Leakage of bone cement into neighboring intervertebral discs: the incidence of diffuse leakage of bone cement into the intervertebral discs during percutaneous vertebroplasty (PVP) is as high as 5% to 25%. The vast majority of intervertebral discs have no clinical symptoms, but there is an increased risk of new fracture of neighboring vertebrae. (5) Leakage of bone cement into paravertebral vein: the incidence of leakage of bone cement into paravertebral vein is 5% to 16.6%, a small amount of leakage has no serious clinical consequences, but a larger amount of leakage can cause pulmonary embolism or localized pain aggravation. (6) Pulmonary embolism: the injected bone cement is thin and large amount, failing to find the large amount of leakage of bone cement into the paravertebral vein and reflux to the branch of pulmonary artery in time, and cause pulmonary embolism. A small amount of pulmonary embolism has no clinical symptoms and is usually found during postoperative chest cT examination. A large number of pulmonary embolism can have typical symptoms of pulmonary embolism such as shock, oxygen desaturation and pulmonary hypertension, and even death, with a very low clinical incidence. The main measures to prevent the complications of bone cement leakage are: (1) bone cement must be injected during the viscous period; (2) injection under fluoroscopic real-time monitoring, once the discovery of more leakage of paravertebral, the injection should be stopped immediately; (3) at the beginning of the injection, the injection speed should be slow, with the bone cement further viscous and then accelerate the injection speed. Spinal infection: Spinal infection is rare after percutaneous vertebroplasty (PVP). Prevention of spinal infection is important, mainly including: (1) poor health or immunocompromised patients, percutaneous vertebroplasty (PVP) can be prophylactic use of antibiotics before the operation; (2) diabetic patients should be controlled in the normal range of blood glucose before the feasibility of percutaneous vertebroplasty (PVP) treatment, and should adhere to the control of blood glucose after the operation; (3) immune suppression, you can add antibiotics in the cement; (4) the cement can be added in the cement, and then injected at the same time, and then injected. (4) Surgical instruments and operating room should be fully sterilized and prepared, and the operator must operate strictly aseptically. Percutaneous vertebroplasty (PVP) rarely causes patient death, and the main causes of death include: injury to the lumbar artery caused by lumbar paracentesis, hemorrhage, percutaneous vertebroplasty (PVP) of more than 8 vertebral bodies in a single operation, and embolization of the pulmonary artery by large amounts of leakage of bone cement, and so on.