BACKGROUND: Inaccurate pedicle screw placement and neurological or vascular injury during spinal instrumentation procedures is both costly and preventable. OBJECTIVES: To determine the comparative efficacy or effectiveness and value for money of the 3D O-arm Surgical Imaging System with Navigation during spinal stabilization surgery compared with standard practice. METHODS: A search of Medical and Health Economic electronic databases (Embase, PubMed, HEED, NHS EED, Cochrane) and conference abstracts up to Nov. 2012 was conducted to identify studies evaluating the effectiveness, efficacy and economics of 3D surgical imaging with navigation. No time or language restrictions were applied. RESULTS: Compared with current practice options, the 3D O-arm surgical imaging with navigation was shown to significantly increase the accuracy of instrument placement, reduce surgeons’ and patients’ exposure to radiation, and offer the opportunity for intraoperative revision for malplaced screws during the index procedure. Results of 10 case series and a European registry show rates of pedicle screw placement accuracy (0 mm to ≤2 mm) between 95% and 100% with 3D O-arm surgical imaging with navigation compared to 84% - 95% reported for various current practice options from multiple meta-analyses. In addition, accuracy rates of between 72% and 92% have been reported for 2D C-arm without navigation. Economic studies demonstrated 3D O-arm surgical imaging with navigation has the potential to reduce the cost of fusion procedures in Europe and the USA by negating the need for pre-operative and post-operative imaging associated with current standard-of-care, reducing the need for reoperations for screw revision, shortening length of procedures and OR time. It has been estimated that it could reduce the cost of hospitalization for spinal surgery by at least 3.8%. CONCLUSIONS: Current evidence shows 3D O-arm surgical imaging with navigation substantially reduces the human and financial burden of patients during spinal stabilization surgery compared with standard practice.