Arthroscopic shoulder surgery, recognized as the gold standard for managing shoulder pathologies, offers numerous advantages due to its minimally invasive approach and favorable recovery profile (1). Optimizing regional anesthesia for these procedures is crucial to ensure adequate analgesia while minimizing side effects associated with general anesthesia, such as sedation and postoperative nausea and vomiting (PONV), thereby enhancing postoperative recovery. However, significant challenges persist, including intraoperative hemodynamic instability and persistent postoperative pain linked to sympathetic hyperactivity and neuroinflammation (2, 3). Traditional peripheral nerve block techniques, notably interscalene brachial plexus block (ISB) (4) and suprascapular nerve block (SNB) (5), have limitations such as rebound pain upon block resolution,¹ diaphragmatic paralysis, and inadequate control of sympathetically mediated pain. These limitations underscore the need for the development and implementation of more advanced or multifaceted analgesic strategies.

SGB provides a dual mechanism of action (6, 7): it stabilizes hemodynamics by suppressing sympathetic overactivity and reduces inflammatory mediators, thereby targeting both nociceptive and neuropathic pain pathways (8). Although SGB has been proven effective in thoracic and vascular surgeries, its synergistic effects with general anesthesia in shoulder arthroscopy remain underexplored. Notably, while interscalene brachial plexus block (ISB) is the current gold standard for perioperative analgesia in shoulder arthroscopy (4, 9), its implementation may be limited by resource constraints or contraindications [e.g., coagulopathy, pre-existing neuropathy, severe chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA) and obesity]. Thus, exploring SGB as an alternative remains clinically relevant. its synergistic effects with general anesthesia in shoulder arthroscopy remain underexplored, which limits evidence-based integration.

This trial evaluates the use of SGB in conjunction with general anesthesia during arthroscopic shoulder surgery. Our findings aim to refine perioperative protocols and improve clinical efficiency.

Shoulder arthroscopic surgery, known for its minimally invasive approach, rapid recovery, and low complication rate, has become the preferred surgical method for treating shoulder disorders (11). However, hemodynamic instability frequently occurs during these procedures due to surgical stimulation and pain (12). Our findings demonstrate that supplementing general anesthesia with a stellate ganglion block significantly attenuated fluctuations in mean arterial pressure and heart rate. This stabilizing effect can be attributed to the ability of SGB to suppress sympathetic nerve overactivity, promote vasodilation, and reduce peripheral vascular resistance, thereby promoting a more balanced cerebral oxygen supply and demand (13). This suggests that the integration of SGB effectively mitigates the surgical stress response and fosters superior hemodynamic maintenance throughout the operation.

Beyond stabilizing intraoperative hemodynamics, SGB exerted a profound impact on the quality of postoperative recovery, primarily through enhanced analgesia. Postoperative pain following shoulder arthroscopy is often dominated by a dull, movement-evoked character, arising from persistent sympathetic hyperactivity and neuroinflammation—elements that are notoriously poorly controlled by conventional peripheral nerve blocks (14). While techniques like the interscalene block provide excellent transient sensory blockade, their resolution can be accompanied by significant rebound pain driven by unresolved inflammatory cascades. Our findings are consistent with those of Uppal et al. (15), who also reported a substantial reduction in postoperative pain scores (approximately 3 points on the VAS at 24 h) following the implementation of a similar analgesic strategy. SGB circumvents this limitation via a multimodal, dual-pathway mechanism. Its selective sympathetic inhibition reduces norepinephrine release, dilates arterioles, and improves microcirculation (16), which in turn attenuates ischemic pain and accelerates the clearance of pro-inflammatory cytokines such as IL-6 and TNF-α (13, 16). These effects collectively blunt central sensitization and suppress pain amplification, which is particularly crucial during shoulder mobilization when tissue tension exacerbates neuroinflammatory signaling (17). Consequently, SGB delivered sustained analgesia that extended beyond 24 h without the characteristic rebound pain, thereby lowering immediate opioid requirements and permitting earlier and less painful engagement in rehabilitation—a key determinant of functional recovery. This aligns with clinical evidence underscoring the mechanistic advantages of sympathetic blockade (18, 19). The magnitude of pain reduction observed in our SGB+GA group not only confirms its efficacy against general anesthesia alone but also suggests a potential advantage over historical reports for brachial plexus blocks (20, 21), indicating that SGB offers a superior, multi-target strategy for managing complex postoperative pain by simultaneously inhibiting sympathetic activity and modulating inflammatory pathways.

The superior analgesia provided by SGB had direct and favorable downstream consequences. The significantly lower consumption of both intraoperative remifentanil and postoperative tramadol in the SGB+GA group provides a clear pharmacological basis for the observed reduction in opioid-induced complications. As nausea, vomiting, and dizziness are frequently driven by opioid use (22), the opioid-sparing effect of SGB—achieved through its dual inhibition of nociceptive transmission and inflammatory cascades (13, 16)—directly translated into a significantly lower incidence of these adverse events.

Ultimately, the synergistic benefits of improved hemodynamic stability, superior analgesia, and fewer complications converged to significantly shorten the hospital stay. Dull pain is a major impediment to active participation in physiotherapy, such as passive range-of-motion exercises. By effectively alleviating this type of pain, SGB enables patients to engage in rehabilitation sooner, accelerating key milestones like independent ambulation and self-care. This accelerated functional recovery is further potentiated by SGB’s opioid-sparing effects, as reduced opioid exposure minimizes sedation and gastrointestinal dysfunction, thereby facilitating earlier mobilization (23). Furthermore, enhanced microcirculation secondary to sympatholysis may also contribute to improved wound healing and a reduced risk of secondary complications like adhesive capsulitis, further expediting the overall recovery timeline.

From a healthcare economics perspective, a reduced length of stay (LOS) decreases direct medical costs and indirect burdens. Our data indicate that SGB could enhance bed turnover rates, a metric with significant implications for resource-constrained environments.

This study has several limitations. Its single-center retrospective design and relatively small sample size may limit the generalizability of the findings. Potential unmeasured confounding factors might also persist. Furthermore, the absence of a direct comparison with brachial plexus blocks, along with the reliance on subjective pain measures rather than objective biomarkers (e.g., IL-6) or multidimensional assessments, restricts a deeper mechanistic understanding of SGB’s therapeutic effects. The optimal dosage and concentration of local anesthetics for SGB also require further investigation. Future research should prioritize multicenter, prospective, three-arm trials incorporating dynamic monitoring of inflammatory biomarkers, standardization of procedural and follow-up protocols, and inclusion of 3-month functional outcomes to comprehensively evaluate the efficacy and recovery impact of SGB.

In shoulder arthroscopic surgery, the combination of SGB with general anesthesia offers numerous benefits. It stabilizes intraoperative hemodynamics, substantially reduces opioid requirements, lowers postoperative pain, minimizes complications, and shortens hospital stays. This combination makes it a valuable option for anesthesia and analgesia, ultimately enhancing patient outcomes and satisfaction. However, the application of SGB should be tailored to each individual patient. A thorough assessment of the patient’s condition is essential to ensure its safe and effective use.

Future research should involve large-sample studies to confirm these results, long-term follow-up to evaluate enduring effects, and multidisciplinary collaboration. This approach will help optimize the use of SGB and enhance patient care.