FDCT systems produce increased scatter radiation, which can result in artifacts and inaccuracies in CT calculations. Anti-scatter grids that may increase patient radiation dose are commonly used to overcome this problem. However, radiation doses are less than that for a single helical CT [7].

Cone-beam CT/FDCT units are increasingly popular for intraoperative minimally invasive surgery [8]. Transpedicular fusions are one area where this technology is being used with success. Some of the touted advantages of modern imaging system use intraoperatively are (1) reduced time for image acquisition compared to repeatedly bringing a conventional fluoroscope into the field, (2) decreased incidence of transgression of the pedicle, (3) reduced overall operating time, and (4) reduced dose of radiation to both the surgeon and the patient. For example, a recent study compared intraoperative computer-assisted spinal navigation to serial radiography for posterior fusions at the L5/S1 level. The navigation system shortened the operative time by about 40 min compared to serial radiographs [9]. More recently, a Japanese group compared isocentric three-dimensional fluoroscopy with navigation to conventional fluoroscopy for percutaneous screw placements. This large study included 300 percutaneous screw placements of which half were inserted with the advanced imaging and half with conventional fluoroscopy. They then evaluated post-procedural accuracy with 2-mm axial slice CT imaging. The authors found that there were 7.3 % exposed screws and zero perforated pedicles in the three-dimensional image group compared to 12 % exposed screws and 3.3 % perforated pedicles in the conventional fluoroscopy group. This was a statistically significant difference for pedicle screw misplacement (P  <  0.05) [10]. In a previous study of conventional two-dimensional fluoroscopy, Weinstein et al. noted a 21 % rate of misplaced pedicle screws, with the vast majority being on the medial side (towards the spinal canal) [11]. The performance of celiac or superior hypogastric plexus neurolytic blocks is potentially impeded by the size of the local tumor burden or lymphadenopathy which may limit spread of the alcohol or phenol neurolytic solution. Other soft tissue structures such as the renal cortex, thoracic duct, abdominal aorta, or inferior vena cava for celiac plexus blocks or the iliac veins, L5/S1 disk, and L5 nerve root for superior hypogastric plexus blocks may be injured by two-dimensional guidance alone. Thus, a three-dimensional imaging system may improve block accuracy and decrease potential complications. Goldschneider et al. [12] used a 3D-RA system to perform celiac plexus blocks in children with good outcomes.

When performing vertebral augmentation procedures, it is normally considered a contraindication to proceed if a retropulsed fragment is pushing posteriorly into the spinal canal, due to the risk of neurological injury as polymethyl methacrylate (PMMA) cement is injected into the vertebral body. Knight et al. demonstrated the utility of CBCT imaging for this exact scenario, however, with a successful vertebroplasty in a patient with a retropulsed bone fragment [13]. The utilization of three-dimensional technology to better treat patients seems likely to grow as the creativity of proceduralists catches up to the capability of the imaging.