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In the field of acute pain medicine research, we believe there is an unmet need to incorporate patient related outcome measures that move beyond reporting pain scores and opioid consumption. The term “minimal clinically important difference” (MCID) defines the clinical benefit of an intervention as perceived by the patient, as opposed to a mathematically determined statistically significant difference that may not necessarily be clinically significant. The present article reviews the concept of MCID in acute postoperative pain research, addresses potential pitfalls in MCID determination and questions the clinical validity of extrapolating MCID determined from chronic pain and non-surgical pain studies to the acute postoperative pain setting. We further suggest the concepts of minimal clinically important improvement, substantial clinical benefit and patient acceptable symptom state should also represent aspirational outcomes for future research in acute postoperative pain management.

AbstractUltrasound-guided interfascial plane blocks are a recent development in modern regional anesthesia research and practice and represent a new route of transmission for local anesthetic to various anatomic locations, but much more research is warranted. Before becoming overtaken with enthusiasm for these new techniques, a deeper understanding of fascial tissue anatomy and structure, as well as precise targets for needle placement, is required. Many factors may influence the ultimate spread and quality of resulting interfascial plane blocks, and these must be understood in order to best integrate these techniques into contemporary perioperative pain management protocols.

During the time period 1984 to the turn of the millennium, interpleural nerve blockade was touted as a very useful regional anesthetic nerve blockade for most procedures or conditions that involved the trunk and was widely practiced despite the lack of proper evidence-based support. However, as an adequate evidence base developed, the interest for this type of nerve block dwindled and very few centers currently use it—thereby to us representing the rest in peace (RIP) I block. Unfortunately, we get a deja-vù sensation when we observe the current fascination with the erector spinae plane block (ESPB), which since 2019 has generated as many as 98 PubMed items. This daring discourse point out the lack of a proper evidence base of the ESPB compared with other established nerve blocking techniques as well as the lack of a proven mechanism of action that explains how this nerve block technique can be effective regarding surgical procedures performed on the front of the trunk. Emerging meta-analysis data also raise concern and give cause to healthy skepticism regarding the use of ESPB for major thoracic or abdominal surgery. Against this background, we foresee that ESPB (and variations on this theme) will end up in a similar fashion as interpleural nerve blockade, thereby soon to be renamed the RIP II block.

Chronic knee joint pain affects millions worldwide, with radiofrequency ablation (RFA) of genicular nerves emerging as a potential treatment in the last 15 years. Despite its growing popularity, with studies demonstrating its efficacy in pain reduction for up to 12 months, recent randomized controlled trials have questioned the efficacy of RFA. Discrepancies in study results may partially be explained by the heterogeneity of patient selection and technical protocols.This daring discourse aims to explore and critically analyze the ongoing debates surrounding RFA of the genicular nerves, addressing key controversies, namely: (1) Is there a role for performing prognostic blocks prior to RFA?; (2) What are the optimal target sites for final cannulae placement for the classical targets?; (3) Which and how many nerves should be targeted in RFA procedures?; (4) What are the comparative benefits of using ultrasound versus fluoroscopy guidance, and whether a combined technique may be advantageous?; (5) Is there a potential role for pulsed radiofrequency of the genicular nerves?; (6) Should genicular nerve RFA be performed after total knee arthroplasty?Through this in-depth discussion, we aim to guide pain medicine clinicians in informed decision-making and encourage further research in this field.

Although interscalene brachial plexus block (ISB) remains the gold standard for analgesia after shoulder surgery, the inherent risks of ipsilateral phrenic nerve block and hemidiaphragmatic paralysis (HDP) limit its use in patients with preexisting pulmonary compromise. In a previous Daring Discourse (2017), our research team has identified potential diaphragm-sparing alternatives to ISB for patients undergoing shoulder surgery. In recent years, the field has been fertile with research, with the publication of multiple randomized controlled trials investigating supraclavicular blocks, upper trunk blocks, anterior suprascapular nerve blocks, costoclavicular blocks, and combined infraclavicular-suprascapular blocks. To date, the cumulative evidence (pre-2017 and post-2017) suggests that costoclavicular blocks may provide similar postoperative analgesia to ISB coupled with a 0%-incidence of HDP. However, in light of the small number of patients recruited by the single study investigating costoclavicular blocks, further confirmatory trials are required. Moreover, future investigation should also be undertaken to determine if costoclavicular blocks could achieve surgical anesthesia for shoulder surgery. Anterior suprascapular nerve blocks have been demonstrated to provide surgical anesthesia and similar analgesia to ISB. However, their risk of HDP has not been formally quantified. Of the remaining diaphragm-sparing nerve blocks, supraclavicular blocks (with local anesthetic injection posterolateral to the brachial plexus), upper trunk blocks, and combined infraclavicular-anterior suprascapular blocks merit further investigation, as they have been shown to achieve similar analgesia to ISB, coupled with an HDP incidence <10%.

The interscalene brachial plexus block is a well-described and widely used peripheral nerve block effective for regional anesthesia and analgesia in orthopedic surgical procedures of the shoulder, upper arm, and clavicle. Conventionally, an in-plane ultrasound-guided approach has been the technique of choice, while the out-of-plane approach, though less described, has been gaining anecdotal momentum among a growing number of proceduralists. This pro-con discussion highlights the out-of-plane approach’s goal of avoiding needle injuries to nerves that course through the middle scalene muscle and the in-plane approach’s benefit of whole-shaft needle visualization and increased distance away from the plexus on entry. We aim to provide a comprehensive comparison to guide proceduralists in their clinical decision-making.

In the age of the opioid epidemic and a widespread desire to reduce opioid prescriptions, both in outpatient practices and hospitals, we have welcomed non-opioid medications as one possible strategy to reduce the reliance on opioids for the treatment of pain. For anesthesiologists, surgeons, and other perioperative physicians, minimizing exposure to opioids in the perioperative period has been a focal point for several decades now and countless protocols have been described, adopted, and studied. Gabapentin and pregabalin, known collectively as gabapentinoids, have been included in many of these protocols and it is not difficult to see why. They have predictable pharmacokinetics, are one of the only medication classes to treat neuropathic pain, and have sizeable literature support for their ability to reduce pain and opioid consumption. Their use for acute perioperative pain remains off-label. As with many drugs, we have learned more over time and now have a fuller picture of the benefits and risks associated with gabapentinoids. In particular, the central nervous system adverse effects, including dizziness and sedation, are now well established and can be especially problematic in the elderly. Synergistic respiratory depression when combined with opioids and even possible cognitive deficits from prolonged use have been described, forcing some perioperative physicians to rethink their inclusion in enhanced recovery and other perioperative protocols. In this pro–con discussion, we debate the merits of perioperative gabapentinoids in 2025, relying on published evidence for our positions, and ultimately call for a nuanced approach that considers the individual patient before us.

Artificial intelligence (AI) tools are currently expanding their influence within healthcare. For pain clinics, unfettered introduction of AI may cause concern in both patients and healthcare teams. Much of the concern stems from the lack of community standards and understanding of how the tools and algorithms function. Data literacy and understanding can be challenging even for experienced healthcare providers as these topics are not incorporated into standard clinical education pathways. Another reasonable concern involves the potential for encoding bias in healthcare screening and treatment using faulty algorithms. And yet, the massive volume of data generated by healthcare encounters is increasingly challenging for healthcare teams to navigate and will require an intervention to make the medical record manageable in the future. AI approaches that lighten the workload and support clinical decision-making may provide a solution to the ever-increasing menial tasks involved in clinical care. The potential for pain providers to have higher-quality connections with their patients and manage multiple complex data sources might balance the understandable concerns around data quality and decision-making that accompany introduction of AI. As a specialty, pain medicine will need to establish thoughtful and intentionally integrated AI tools to help clinicians navigate the changing landscape of patient care.

In Regenerative Medicine, the quest to harness the body’s own healing potential is as much a philosophical journey as it is a clinical challenge. Promising interventions—from platelet-rich plasma injections to stem cell therapies—often differ in subtle yet critical ways, leading to variable outcomes. One method might modestly enrich bioactive components, while another yields a preparation bursting with regenerative signals. This variability compels us to ask: should we focus on merely categorizing these diverse approaches, or instead strive to define the fundamental nature of the therapeutic agents we deploy?This Daring Discourse explores the tension between the intricate diversity of human biology and our need for consistency and reproducibility in treatment. Drawing on the parable of the blind men and the elephant, it illustrates how isolated perspectives reveal only fragments of the truth; only by integrating these views can we grasp the full regenerative potential. It further cautions against the rise of “spin wizards”—clinicians who, relying solely on centrifugation without understanding underlying biological determinants, claim a universal cure for degenerative conditions.This narrative advocates for a unified framework that marries innovative techniques with rigorous standardization. Such an approach promises to transform Regenerative Medicine from a field of hopeful experiments into one where treatments are reliably safe and effective, ultimately fulfilling its transformative potential.

Artificial intelligence (AI) has demonstrated a disruptive ability to enhance and transform clinical medicine. While the dexterous nature of anesthesiology work offers some protections from AI clinical assimilation, this technology will ultimately impact the practice and augment the ability to provide an enhanced level of safe and data-driven care. Whether predicting difficulties with airway management, providing perioperative or critical care risk assessments, clinical-decision enhancement, or image interpretation, the indications for AI technologies will continue to grow and are limited only by our collective imagination on how best to deploy this technology.An essential mission of academia is education, and challenges are frequently encountered when working to develop and implement comprehensive and effectively targeted curriculum appropriate for the diverse set of learners assigned to teaching faculty. Curriculum development in this context frequently requires substantial efforts to identify baseline knowledge, learning needs, content requirement, and education strategies. Large language models offer the promise of targeted and nimble curriculum and content development that can be individualized to a variety of learners at various stages of training. This technology has not yet been widely evaluated in the context of education deployment, but it is imperative that consideration be given to the role of AI in curriculum development and how best to deploy and monitor this technology to ensure optimal implementation.