Local spinal pain and radiculopathy are common conditions that debilitate millions of Americans annually. Most cases are successfully treated conservatively with rest or physical therapy. Chiropractic manipulation or, in some cases, surgery may also be performed. Percutaneous injection has been used for spinal pain management for many years, but many of these procedures have historically been performed without imaging guidance. Recently, however, newer minimally invasive, imaging-guided percutaneous techniques have been added to the list of available treatment options for spinal pain. Imaging-guided techniques with fluoroscopy or computed tomography increase the precision of these procedures and help confirm needle placement. Cervical, thoracic, lumbosacral, and sacroiliac pain can be evaluated and treated safely and effectively with injections of local anesthetics or long-acting steroids into facet joints, sacroiliac joints, selective nerve roots, spondylolytic areas, and the epidural space. Because imaging-guided techniques appear to provide better results and reduce complication rates, they are becoming more popular despite controversy regarding their effectiveness. Controversy will continue to surround these imaging-guided techniques until large, double-blinded studies become available. In the meantime, there is an increased demand for these procedures from referring physicians, and it is important to be able to safely perform them with a minimum of patient discomfort.