PURPOSE Percutaneous cementoplasty is a minimally invasive treatment modality for painful osteoporotic and pathologic sacral and supra-acetabular iliac fractures. This study compares the use of low-dose CT guidance with CT/CT fluoroscopy in sacral and supra-acetabular cementoplasty. METHODS A retrospective review of patients who had undergone sacral or supra-acetabular cementoplasty was performed with patients grouped by use of CT/CT fluoroscopy or low-dose CT guidance during the procedure. Parameters evaluated included type of fracture, laterality of lesions, pain scores, pain medication use, imaging parameters, procedure time, dose-length product, effective dose, cement volume, and complications. RESULTS There were 17 patients identified who underwent cementoplasty utilizing dual CT/CT fluoroscopy, while 13 patients had their procedures performed with low-dose CT. There was a statistically significant decrease in radiation dose in the low-dose CT group (1481 mGy·cm) compared with the CT/CT fluoroscopy group (2809 mGy·cm) (P = 0.013). There was a significant decrease in procedure time with low-dose CT for bilateral lesions (P = 0.016). There was no significant difference between groups in complication rate (P = 0.999). Clinically nonsignificant cement extravasation occurred in two patients (10%) in the CT/CT fluoroscopy group and in one patient (8%) in the low-dose CT group (P = 0.999). There was a significant decrease in pain scores compared with baseline on the visual analogue scale in both groups at 1 week (low-dose CT P = 0.002, CT/CT fluoroscopy P = 0.008) and 1 month postprocedure (low-dose CT P = 0.014, CT/CT fluoroscopy P = 0.004), but no difference between groups at 1 day (P = 0.196), 1 week (P = 0.368), or 1 month (P = 0.514). CONCLUSION Sacral and supra-acetabular cementoplasties can be performed safely and precisely using low-dose multiple-acquisition CT guidance while providing significant radiation dose reduction with no difference in extravasation rates, postprocedural pain reduction, and complications compared with CT/CT fluoroscopy.