The purpose of this review is to present a comprehensive summary of commonly used methods of spinal image guidance, including the benefits and limitations of this novel technology.The relevant medical literature was examined, supplemented by the author's laboratory and clinical experience with image-guided spinal surgery.Spinal image guidance has undergone significant evolution and rapid technological advancement in recent years. Image guidance provides three-dimensional visualization of the spine that can be used for preoperative planning and intraoperative navigation. There are three commonly used methods of spinal image guidance: preoperative CT-based, fluoroscopy-based, and 3D fluoroscopy. Each of these methods demonstrates lower rates of spinal implant misplacement than non-image-guided techniques.Image guidance provides highly accurate intraoperative navigation and the medical literature suggests that this technology increases the safety of a variety of routine and complex spinal procedures.