Systems and methods for accessing the spine include tissue penetrating members with direct visualization capability that may be used to form an access pathway to a targeted treatment site. The direct visualization capability, which may be provided by fiberoptic illumination and imaging components, may be use to visualize the tissue as the access pathway is formed by the tissue penetrating member. The tissue penetrating members include catheters and cannulas with sharpened tips with integrated fiberoptic components and/or channels in which a fiberscope or miniscope may be inserted. Apertures and/or transparent materials are provided to permit imaging of tissue about the distal end of the tissue penetrating member.