Erector Spinae Plane Block Versus Thoracic Paravertebral Block for Postoperative Analgesia in Thoracic Surgery: A Systematic Review and Meta-Analysis of Randomized and Observational Studies

Background/Objectives: Both erector spinae plane block (ESPB) and thoracic paravertebral block (TPVB) are widely used for thoracic surgery analgesia, but comparative evidence remains inconsistent. This meta-analysis compared their analgesic efficacy and safety with time-stratified analyses and trial sequential analysis (TSA). Methods: We searched MEDLINE, Embase, Web of Science, and CENTRAL (inception to January 2026) for randomized controlled trials (RCTs) and observational studies comparing ESPB with TPVB in adults undergoing thoracic surgery. Primary outcomes were pain scores at rest and during coughing at 0–6 h, 24 h, and 48 h postoperatively. Secondary outcomes included opioid consumption and adverse events. Random-effects meta-analyses were performed. Evidence certainty was assessed using GRADE. Results: Twenty-five studies (22 RCTs, 3 observational studies; 1847 patients) were included. TPVB provided superior early analgesia (0–6 h) at rest (SMD 0.25, 95% CI 0.03–0.47) and during coughing (SMD 0.28, 95% CI 0.02–0.54); TSA confirmed firm evidence for early pain at rest. Pain scores at 24 h and 48 h were comparable between techniques. TPVB reduced 24 h opioid consumption (SMD 0.42, 95% CI 0.11–0.73), but evidence certainty was low due to heterogeneity and insufficient information size by TSA. No differences were observed in postoperative nausea and vomiting or hypotension. Conclusions: ESPB and TPVB provide comparable analgesia beyond the early postoperative period. TPVB demonstrates superior early analgesia (0–6 h) with firm evidence, but opioid-sparing effects remain uncertain. Both techniques are safe. ESPB represents a practical alternative to TPVB, particularly where technical simplicity is prioritized.