Abstract: Objective To compare the clinical efficacy of 3 approaches of vertebroplasty in the treatment of severe osteoporotic vertebral compression fractures.Methods Twenty-five patients with severe osteoporotic vertebral compression fractures were observed,whose average age was 72 years with average disease history of 12 days and average compression of the affected vertebral bodies of 73%.The patients were divided into 3 groups for 3 different fracture types according to Rao’s classification of osteoporotic vertebral structure and deformity,namely wedge type(group A,n= 12),biconcave type(group B,n= 7)and crush type(group C,n=6).Unipedicular approach was adopted in group A,far lateral bipedicular approach in group B,and posterior wall vertebroplasty and pedicle screw fixation in group C.The average follow-up time was 1 year.Visual analog scale(VAS),analgesic use and the mobility were measured in the patients preoperatively and 3 days(7 days in group C)and 6 months after the operation,respectively,and the success rates and complications were observed.Results All the surgical procedures were successful.The average operation time was 35 min in group A,50 min in group B,and 2 h in group C.The average volume of cement injected into each vertebral body was 2.0 ml.The average blood loss was 30 ml in groups A and B,and 600 ml in group C.The procedure increased mobility and decreased analgesic use.VAS was decreased by a mean of 4.8 in Group A,6.2 in group B 3 days after the operation and 5.4 in group C 7 days postoperatively,and remained stable till 6 months after the operation(P<0.01).Cement extravasation occurred in 9 cases,cement in the vertebral canal in 2 cases with transient neurological symptoms,and cement extravasation in the intervertebral space and the anterior space of the vertebral bodies took place in 5 and 2 cases,respectively.No neurological complications were observed.Conclusion Different types of severe osteoporotic vertebral compression fractures require management with different approaches of vertebroplasty for adequate filling of the remaining vertebral body,which provides significant pain relief with wider indications.