The future of pain anesthesiology stands at a pivotal juncture. Once a thriving domain led by pain medicine anesthesiologists, the sector has been significantly influenced by recent technological advancements, alterations in insurance policies, and the growing influence of patient advocacy. These factors have begun to reshape the industry's landscape. 

Pain medicine anesthesiologists who once dominated private pain management clinics are now facing a reckoning due to factors such as insurance crackdowns on epidural steroid injections (ESIs), a surge in complication-related lawsuits (including for spinal CSF leaks), and the growing use of advocacy for correct use of opioids to be restored as a safer method of pain management that patients trust. 

Applications for pain fellowships have drastically declined, plummeting by 45% since 2019, with 36 program spots remaining unfilled in 2024. In stark contrast, the spinal leak care market is experiencing a surge, with hospitals rushing to rectify botched procedures from pain medicine clinics, often termed “drill mills”. These clinics, struggling to maintain financial stability, resorted to packing patients into rapid schedules of quickly performed ESIs, which frequently led to spinal leaks. 

This transformation raises big questions: How will robotic anesthesia advancements change pain management? Will AI in pain management make human anesthesiologists obsolete? And why is the spinal leak market suddenly gaining so much attention?

The Changing Landscape of Pain Anesthesiology

This article will explore three game-changing developments unfolding in the pain management field today:

• The future of pain anesthesiology as AI and robotics transforms anesthesia.
• Genomics and wearable technology will play a more prominent role in the future of pain medicine.
• The spinal leak care gold runs where savvy regional anesthesiologists are cashing in on a market valued at over a trillion dollars. 

The Decline of Pain Medicine Anesthesiology

Pain Medicine fellowships were once considered the golden ticket for anesthesiologists who wanted to enter private practice immediately. In contrast, those who planned to work in hospitals typically chose Acute Pain Medicine, Regional Anesthesia, and Obstetric Anesthesiology fellowships. 

Pain management clinics were booming as Big Tech promoted neuromodulation devices as the next big thing, and insurance companies generously reimbursed for ESIs. 

The glory days of pain medicine finally came to an end as insurance fraud scandals, declining patient trust, and regulatory crackdowns have made it increasingly difficult for pain medicine anesthesiologists to thrive. 

The American Board of Anesthesiologists (ABA) has been criticized for having misplaced priorities by focusing heavily on neuromodulation in board exams while barely covering crucial procedures like epidural blood patches for cerebrospinal fluid (CSF) leaks. 

The Insurance Reimbursement Crisis

Pain medicine practices took a significant hit in 2024 when insurance companies tightened reimbursement policies for their bread and butter: epidural steroid injections. The use of ESIs has always been controversial (its efficacy has been debated since 2004), and their widespread use was driven more by financial incentives than patient outcomes. Many pain management clinics are now struggling to stay afloat as more stringent reimbursement restrictions are implemented. 

Meanwhile, hospital-based anesthesiologists are watching from the sidelines, falsely believing that pain medicine specialists are better equipped for private practice. The pain medicine niche is floundering, and a significant market gap is opening in the overlooked but highly demanded field of CSF leak care. 

Innovations in Pain Anesthesiology: Robotic Anesthesia and AI in Pain Management

As we move towards a future where robot-assisted surgery is a reality, the potential of AI to handle complex calculations in real time, adjust for epidural injections, and monitor patient responses faster and more accurately than a human could is promising. This advancement in technology is not meant to replace human expertise but to enhance it, making the future of pain management a more efficient one. 

In 2022, a proof of concept paper was released on an autonomous spinal robotic system for transforaminal lumbar epidural injections. The paper showed varying needle point accuracy rates based on the placement and angular orientation of the needle compared to freehand techniques. The value for epidural blood patches is immense here, with a successful blood patch producing life-changing results. Still, there is a high variance between physicians on performance, often causing complications based on specialty (such as radiology versus anesthesiology) and amount of personal blood patch training and practice by each physician. 

AI in pain management is also transforming the industry. The days of one-size-fits-all approaches to pain medicine are fading as AI makes it easier to tailor treatments to individual patients, from predicting pain scoring to personalized pain management protocols. The future of chronic pain management is precision medicine that harnesses the power of AI and genomics to determine optimal treatment plans for each patient. 

Next-Generation Pain Treatments

Artificial intelligence and robotics are not the only technologies transforming the healthcare landscape. While pain medicine physicians talk at length about regenerative medicine as an alternative to opioids, the U.S. Food and Drug Authority (FDA) continually has to release warnings about the use of unregulated regenerative medicine products.

These products require FDA licensure and approval to be offered to patients and undergo clinical trials. Yet some pain medicine physicians are illegally marketing unregulated items to patients as cure-alls. 

Unapproved products, the FDA notes, are those “recovered from your own body or another person’s body”. They can include “stem cells, stromal vascular fraction (fat-derived cells), umbilical cord blood and/or cord blood stem cell, amniotic fluid, Wharton’s jelly, ortho-biologics, and exosomes.”  

The FDA has had to issue continuous warnings on this issue, and the Federal Trade Commission (FTC) has shut down the illegal marketing of these items as cure-alls multiple times due to the high level of consumer-reported financial losses and physical harm.

Our email-based survey of pain medicine anesthesiologists in the US included physicians specializing in regenerative medicine. Many of these physicians attempted to upsell our campaign, presented as a patient reaching out with a clear-cut spinal leak case. 

One offer was to inject plasma-rich platelets (PRP) intrathecally, which involves intentionally puncturing the dura–thus creating a new dural hole and likely a spinal CSF leak–and introducing matter into the cerebrospinal fluid (CSF), presenting a risk for meningitis. When this physician was challenged on why they would not follow the American Society of Anesthesiologists (ASA) guidelines on addressing a spinal leak, the anesthesiologist reported following regenerative medicine guidelines instead. 

There are a few reported cases of stem cells and alternative methods for repairing a spinal CSF leak, but this presents an ethical dilemma where highly vulnerable patients are being given as an option experimental treatment that is under-researched outside of the highly-researched epidural blood patch, which has been upheld as the gold standard treatment for spinal leaks for decades.

While many hospital-based anesthesiologists may feel behind the times and out of the loop to participate in next-generation pain medicine approaches, old school is about to become the new school. 

The epidural blood patch, which has been down-phased in much current residency training in anesthesiology residencies per private reports from anesthesiologists to us, is mainly available in training to anesthesiologists in hospital-based settings who can gain experience on the job. 

Recent research has finally started exploring aspects of the tool, such as blood quality. In 2022, an article by a Korean anesthesiologist made waves among the American Society of Anesthesiologists (ASA) as a paper summarizing current knowledge across disciplines on spinal CSF leaks and epidural blood patches–albeit making some statements that have been disproven by other research.     

Considering the number of spinal leak patients that are on opioids or opioid alternatives due to lack of correct diagnosis and inaccessibility of quality blood patches, it is clear that in cases of fixable injury, access to correct care is crucial. A spinal CSF leak produces more than just a headache, and the cases of spinal leak patients on medication for pain show that these patients are still often unable to work due to the many other secondary conditions created by the spinal leak, such as secondary postural orthostatic tachycardia syndrome (POTS).  

Some regional anesthesiologists leaving hospital systems attempt to catch up on regenerative medicine offerings in private practice with what they perceive as being within their wheelhouse for non-invasive approaches, such as red light therapy.

However, these anesthesiologists fail to recognize a crucial skill they have to offer: the epidural blood patch. The epidural blood patch works in two parts: forming a seal at the dural hole and promoting fibroblast activity. It is–in its very essence–regenerative. 

Anesthesiologists should work with dietitians who specialize in spinal leak patients to enhance the regenerative effect of blood in malnourished patients who have gone years without care. For example, if patients have Vitamin K deficiencies affecting clotting and B12 and iron deficiencies affecting wound healing and blood quality, these can impair the regenerative effects of blood. This is the actual future of regenerative medicine. 

Future Trends in Epidural Technology

Epidural technology is also evolving, and the future of pain anesthesiology will see: 

• Improved needle designs that lower the rate of complications.
• AI-powered guidance systems for increased accuracy.
• Innovations that minimize infection risks.

As technology advances, hospital-based anesthesiologists are in a prime position to integrate these innovations—especially in spinal leak care, where traditional pain management has failed.

The Future of Pain Medicine: A Shift Away from Outdated Practices

The pain medicine industry traditionally relied on a business model prioritizing quick procedures and high patient turnover. However, that model is now collapsing due to insurance crackdowns, rising patient skepticism, the increasing demand for precision medicine, and the growing demand within healthcare consumerism for concierge care models with excellent customer service and a positive patient experience. 

While there is a push for non-opioid approaches, it is crucial to recognize that for certain incurable conditions–such as sickle cell disease–opioids, when used correctly, remain an essential part of treatment, especially as patients often tolerate them well alongside complementary therapies. 

At the same time, improving access to definitive care–like blood patches for spinal leak patients–is just as crucial as some patients may manage the pain component effectively but still struggle with low mobility and other secondary problems until the underlying issue of a dural injury is addressed. 

Emerging Technologies in Pain Management

New technologies are changing how physicians approach managing pain, offering hope for patients who have been stuck in an endless cycle of misdiagnoses and ineffective procedures. 

Some of the ways technology is transforming pain medicine include:

Telehealth for chronic pain patients

Virtual consultations and remote monitoring devices allow patients to receive expert care without visiting a clinic. This opens up specialized care to patients in underserved areas or those who can’t leave their homes.

Precision medicine for chronic pain

Genomics could revolutionize physicians' approaches to chronic pain management. It can analyze patients' genetic makeup and predict the most effective treatments.

The Death of the Traditional Pain Clinic?

For years, pain management clinics thrived by adhering to a simple formula: get patients in, administer ESIs, schedule a follow-up visit, and repeat the process. However, insurance provider crackdowns now limit reimbursement for excessive ESIs, leaving many pain medicine clinics struggling to stay afloat.

Traditional pain management clinics routinely failing to address the root causes of chronic pain and opting to put financial incentives over best outcomes for patients has now created a market gap that forward-thinking anesthesiologists can help fill. 

Interdisciplinary Pain Clinics: The New Standard?

Rather than relying on outdated interventions, the future of pain medicine is moving toward interdisciplinary pain clinics that combine:

• Anesthesiology expertise for procedural interventions.
• Physical therapy to address musculoskeletal imbalances.
• Psychological support to help with medical trauma. 
• Nutrition and lifestyle coaching to improve long-term health outcomes. 

The Spinal Leak Care Market: A Rising Opportunity

The demand for cerebrospinal fluid (CSF) leak treatment has grown considerably despite the struggles traditional pain clinics are currently going through. Spinal leaks, many caused by conventional pain clinics administering ESIs as a default treatment for chronic pain, have been underdiagnosed, mismanaged, or outright ignored for years, often by the pain medicine anesthesiologists who should be treating them. 

The spinal leak care market is now valued at over a trillion dollars, creating a lucrative opportunity for anesthesiologists with experience administering EBPs who want to leave hospital systems. 

Why Is the Spinal Leak Care Market Growing?

A spinal CSF leak typically occurs when the protective fluid around the spinal cord drains into other areas due to a dural puncture or tear. It can also occur as a result of trauma to the body that damages the dural. 

Clinical procedures that come with a risk of creating spinal leaks include lumbar punctures (often used by traditional pain management physicians to diagnose spinal CSF leaks despite research suggesting that minimally invasive diagnostic tools like the Bern Score are more effective), epidural injections, spinal anesthesia, and multiple other procedures. 

The result of many specialists misdiagnosing and mistreating spinal leaks has been a growing number of people (women, in particular, due to the use of epidural injections during labor) living with debilitating headaches, dizziness, nausea, and cognitive issues that leave some bedridden. 

Pain medicine anesthesiologists have historically failed to master the art of administering epidural blood patches (EBPs) due to a lack of hospital-based work experience. However, EBPs are the gold-standard treatment for spinal leaks, backed by the latest research. Other anesthesiologists skilled in EBPs now have the opportunity to enter pain medicine and specialize in spinal CSF leak care and epidural blood patch administration. 

The demand for competent spinal leak care continues to grow as more spinal leak patients realize conventional pain management isn’t working for them, while paying as much as $20,000 yearly on conservative treatments like IV saline that don’t address dural punctures or tears. 

The key factors responsible for the fast-growing spinal leak care market include: 

• Rising awareness among patients: Online forums, social media, and advocacy groups are helping patients to identify the symptoms of spinal leaks and demand proper treatment. 
• Limited number of skilled practitioners: Many pain management specialists don’t have much experience administering epidural blood patches, creating a massive demand for anesthesiologists who regularly perform the procedure while working in hospitals to enter private practice, further enhance their EBP knowledge, and provide this much-needed procedure. 
• Advancements in spinal CSF leak treatments: Innovations like image-guided EPBs and a focus on the role of nutrition in blood quality improve patient outcomes. 
• Increased investment in diagnostic technology: Magnetic resonance imaging (MRI) and non-invasive digital subtraction myelography (DSM) have become more widely available to detect spinal leaks.

Spinal leak care is a lucrative opportunity for hospital-based anesthesiologists transitioning into private practice. The cerebrospinal fluid leak market forecast predicts continued growth in the coming years. 

Insurance reimbursement rates for procedures like epidural blood patches should rise as providers realize the error of their previous approach to spinal leak care and patients seek out cash-based concierge care. 

If you're an anesthesiologist with solid procedural skills in epidural blood patches, there’s never been a better time to specialize in spinal leak care. 

Taking Action: How Anesthesiologists Can Step into the Future

The traditional pain medicine model is collapsing due to fraud, ineffective treatments, and over-reliance on neuromodulation devices backed by big tech that has overshadowed the field, leaving many pain medicine anesthesiologists scrambling to keep up with their overhead costs. 

Meanwhile, a golden opportunity has opened up for general anesthesiologists, regional specialists, and hospital-based pain experts to jump into private practice and step in where their counterparts have failed in areas like spinal leak care.  

Some of the steps anesthesiologists looking to start private practice should take include:

Step 1: Reclaim Procedural Expertise

Pain medicine anesthesiologists built their careers on epidural steroid injections, but insurance companies have now cracked down on ESI use, leaving many searching for a new business model. Anesthesiologists with strong epidural skills are already a step ahead of them. 

Consider adding skills like fluoroscopy-guided epidural blood patches to treat CSF leaks if you want to move into private practice. 

Step 2: Train in Spinal Leak Diagnosis and Treatment

Hospitals have long relied on interventional radiologists to diagnose spinal leaks, but many aren’t trained in epidural blood patching, leading to botched procedures. Anesthesiologists looking to transition to private practice focused on spinal leak care should: 

• Get trained in fluoroscopy and image guidance for epidural blood patches to reduce patient risk. 
• Stay up to date on the latest innovations regarding spinal leak treatment. 
• Consider home-based spinal leak recovery models for bedridden patients, such as streamlined care to support the patient outside the epidural blood patch (EBP).

Step 3: Build a Practice That Works for You

Pain medicine clinics are closing down all over the country, while you, as an anesthesiologist with procedural skills, are positioned to offer high-value services that improve patients' short—and long-term outcomes.

Some of the things you can do to separate your practice from conventional pain management specialists include:

• Prioritize treating root causes of pain instead of focusing only on providing relief. For example, research has shown that opioids, caffeine, and other pain management techniques can be supportive in helping manage the pain caused by PDPH if the patient tolerates them well, and an epidural blood patch would help close up the CSF leak, addressing the root cause. 
• Focus on minimally invasive procedures and precision medicine for chronic pain. 
• Set up an interdisciplinary pain clinic that combines anesthesiology, regenerative medicine, and evidence-based pain relief. 

Seizing the Moment: The Future of Pain Medicine Belongs to You

Traditional pain medicine anesthesiologists left a trail of destruction and lawsuits, leading to insurance companies cutting off their lifeline. A new wave of anesthesiologists are now stepping up to take their place. 

The future of pain anesthesiology belongs to physicians willing to adapt. Contact our marketing team to explore possibilities.