Purpose <p>Phosphaturic mesenchymal tumor (PMT) is an ultrarare neoplasm responsible for tumor-induced osteomalacia (TIO). Spinal involvement is exceptionally uncommon, and the diagnostic and therapeutic strategies for spinal PMT remain inadequately defined. This report aims to present a case of thoracic vertebral PMT and review the clinical features, diagnostic challenges, and surgical management of spinal PMTs.</p> Methods <p>We reported a 60-year-old male patient presenting with recurrent low back pain and persistent hypophosphatemia. Comprehensive imaging, including CT, MRI, and ¹⁸F-AlF-NOTA-octreotide PET/CT, was performed. Given the hypervascularity of the lesion, preoperative segmental artery embolization was conducted to reduce the risk of massive intraoperative hemorrhage. En-bloc tumor resection combined with posterior spinal stabilization was subsequently performed. The literature of previously reported spinal PMT cases was also reviewed.</p> Results <p>Imaging revealed an osteolytic lesion involving the T11 vertebral body and right pedicle with significant contrast enhancement on CT and MRI. ¹⁸F-AlF-NOTA-octreotide PET/CT demonstrated intense uptake in the tumor lesion, and histopathology confirmed the diagnosis of classical type PMT. Preoperative embolization effectively reduced intraoperative blood loss, enabling complete tumor resection. Postoperatively, serum phosphorus level normalized within one week, and his symptoms resolved completely. No recurrence was observed during six months of follow-up.</p> Conclusion <p>Spinal PMT, though rare, should be considered in patients with unexplained hypophosphatemia and osteopenia. ¹⁸F-AlF-NOTA-octreotide PET/CT is a valuable tool for tumor localization. Preoperative embolization is an effective adjunctive strategy to reduce intraoperative hemorrhage for hypervascular spinal PMTs. Complete surgical resection remains the definitive treatment, offering excellent biochemical and clinical outcomes.</p>