Beyond the blind epidural: sensing, robotics, and artificial intelligence for safer neuraxial anesthesia

Neuraxial block techniques, including lumbar and thoracic epidural blockade, and spinal anesthesia, are not entirely accurate or reliable. Cerebrospinal fluid return confirms intrathecal access during spinal anesthesia; epidural placement relies heavily on subjective loss of resistance, supplemented after catheter insertion by aspiration for blood or cerebrospinal fluid, response to a test dose when appropriate, and clinical assessment. This Daring Discourse proposes objective sensing, standardized performance reporting, and ultimately, robotic and artificial intelligence assistance as a path to safer, more reproducible practice. Variable outcomes may be attributed to inconsistent definitions of efficacy and side effects, subjective needle insertion endpoints, uncertainty over catheter positioning, and operator cognitive overload. Opportunities for improvement include consistent adoption and reporting of established key performance indicators, better procedural planning and guidance, objective sensing of tissue planes, catheter tip position, and improved operator feedback. A modular development path could combine preprocedural imaging, real-time sensing, artificial intelligence–based interpretation, and, where justified, supervised robotic assistance; not every procedure requires every component. However, technical performance alone will not guarantee adoption. New technologies must also be easy to learn, quick to set up, interoperable, and cost-effective. Health-economic evaluation should compare their full costs with potential improvements in safety, patient experience, and workflow. The goal is not technology for its own sake but scalable assistance that improves safety, efficiency, and accountable clinical decision-making.