An expanding array of image-guided spine interventions have the potential to provide immediate and effective pain relief. Innovations in spine intervention have proceeded rapidly, with clinical adoption of new techniques at times occurring before the development of bodies of evidence to establish efficacy. Although new spine interventions have been evaluated by clinical trials, acceptance of results has been hindered by controversies regarding trial methodology. This article explores controversial aspects of four categories of image-guided interventions for painful conditions: spine interventions for postdural puncture headache resulting from prior lumbar procedures; epidural steroid injections for cervical and lumbar radiculopathy; facet and sacroiliac joint pain interventions; and vertebral augmentations for compression fractures. For each intervention, we summarize the available literature with an emphasis on persistent controversies and discuss how current areas of disagreement and challenge may shape future research and innovation. Despite the ongoing areas of debate for various aspects of these procedures, effective treatments continue to emerge and show promise for aiding relief on a range of debilitating conditions.