A systematic review and meta-analysis of six randomized controlled trials with 365 patients investigated the efficacy of erector spinae plane block (ESPB) for pain relief after arthroscopic shoulder surgery. ESPB did not reduce cumulative opioid consumption in the first 24 hours compared to control (SMD -1.11; 95% CI -2.55 to 0.33; p = 0.13, I² = 96%). Pain scores were lower at 2 hours (SMD -0.83; 95% CI -1.30 to -0.37; p = 0.0005, I² = 35%) and at 48 hours (SMD -0.64; 95% CI -1.08 to -0.20; p = 0.0042). ESPB increased time to first rescue analgesic request (SMD 4.04; 95% CI 0.77 to 7.31; p = 0.02, I² = 99%). However, it did not reduce pain scores at rest or with movement at 2 hours (SMD -0.87; 95% CI -2.98 to 1.24; p = 0.42; I² = 97%; SMD -0.98; 95% CI -3.00 to 1.04; p = 0.34) or the incidence of postoperative nausea and vomiting (PONV), with comparable adverse events. Analysis of the single-injection subgroup showed no opioid sparing (SMD -1.46; 95% CI -3.21 to 0.30; p = 0.10, I² = 97%). Patient satisfaction did not differ from the control group. PROSPERO registration: CRD42023395027.