Combined regional anesthesia versus general anesthesia for elective shoulder arthroscopy: a prospective randomized trial of postoperative pain, with an exploratory cost analysis

Shoulder arthroscopy causes substantial postoperative pain and operating room resource use. Randomized trials integrating postoperative pain trajectory with sensitivity-tested cost analysis are limited. We compared combined three-block regional anesthesia with standard general anesthesia in elective shoulder arthroscopy.

In this prospective, randomized, parallel-group, single-center trial, 50 adults undergoing elective shoulder arthroscopy in the beach-chair position were allocated 1:1 to ultrasound-guided combined interscalene, supraclavicular, and superficial cervical plexus blocks with dexmedetomidine sedation or standard general anesthesia. The primary outcome was the resting Numeric Rating Scale (NRS, 0-10) pain score at 4 h. Pre-specified secondary outcomes included pain scores at the remaining timepoints, movement-evoked pain, patient and surgeon satisfaction, surgical duration, and intraoperative opioid consumption. Exploratory post-hoc outcomes included cumulative pain burden (area under the NRS-time curve), total perioperative cost, hemodynamic parameters, perioperative time components, rescue analgesia, postoperative nausea and vomiting, and complications.

Resting NRS at 4 h was lower with regional anesthesia than with general anesthesia (median 0 [IQR 0-0] vs. 4 [IQR 3-5]; Hodges-Lehmann median difference 4 points, 95% CI 3 to 4; p < 0.001) and remained lower through the 4-hour timepoint. Movement NRS increased at 12 and 24 h after block regression. Among the pre-specified secondary outcomes, patient and surgeon satisfaction was higher with regional anesthesia, while surgical duration was similar. In exploratory post-hoc analyses, the 24-hour cumulative pain burden was lower with regional anesthesia, total perioperative cost was approximately 38% lower with regional anesthesia across all sensitivity scenarios, total operating room time was shorter, and complication types differed qualitatively between groups with no significant difference in incidence detected.

Combined regional anesthesia provided superior early analgesia and greater patient and surgeon satisfaction than general anesthesia. Exploratory post-hoc analyses suggested lower 24-hour cumulative pain burden, lower total perioperative cost and shorter operating room utilization. These economic and operational findings should be considered hypothesis-generating.

Clinicaltrials Registration No: NCT06674954, Date: October 16, 2024.