Management of pain is an essential responsibility in medicine. With the advance of surgical technologies, the use of interventional and other invasive methods to treat pain has become prominent and growing in use. Yet, rarely are these techniques evaluated in a way that can separate their specific impact on pain from expectation and context effects that these rituals share with many other less invasive approaches to pain. In this chapter we examine invasive studies for pain that are compared to sham procedures that mimic the procedure without delivering actual surgery. We describe studies for angina, low back pain, osteoarthritis, and headache, examining quality and outcomes. Remarkably, when compared to a sham group, most invasive procedures do not produce a significant effect on pain. We explore clinical and ethical implications of these data and recommend that more rigorous research be done on invasive procedures before they are adopted for widespread use.