Continuous erector spinae plane block for robotic-assisted thoracic surgery in lung cancer: a dual-center retrospective propensity-score weighted cohort study

Background Postoperative analgesia remains challenging in thoracic surgery, particularly with the rise of Robotic-Assisted Thoracoscopic Surgery (RATS). The Erector Spinae Plane Block (ESPB) is a promising opioid-sparing technique, but its role in RATS is unclear. Methods In this retrospective dual-center cohort study, we included 78 patients with lung cancer undergoing RATS, who received general anesthesia with or without ESPB. ESPB involved a single shot of 30 mL of 0.5% ropivacaine injection at T7, followed by a 24-hour infusion of 0.2% ropivacaine (7 mL.h⁻¹). The primary outcome was opioid rescue within 36-hours. Secondary outcomes included hospital length of stay and chest tube duration. Confounders were balanced with Inverse Probability Treatment Weighting (IPTW). Results In unadjusted analyses, there was no significant difference in rescue opioid consumption between groups (ESPB 37.8% vs. GA 27.3%; p = 0.46). After propensity score weighting to improve covariate balance, ESPB use was associated with lower postoperative opioid requirements (OR = 0.57; 95% CI 0.32–0.79; p = 0.01). This finding may reflect improved adjustment for measured confounders, although residual confounding cannot be excluded. In contrast, chest tube presence within 24-hours was associated with higher opioid requirements (OR = 2.32; 95% CI 1.22–4.20; p = 0.04). ESPB patients also required fewer scheduled opioids during the first 24–36h postoperatively (p = 0.03). Conclusion In this observational cohort, ESPB use was associated with lower postoperative opioid requirements in RATS. These findings suggest a potential role for ESPB within ERAS pathways, although randomized studies are needed to confirm efficacy and define its role in minimally invasive thoracic surgery.