Erector spinae plane block for postoperative analgesia after hip surgery: a systematic review and meta-analysis of randomized controlled trials

Background Erector spinae plane block (ESPB) has been evaluated for postoperative analgesia after hip surgery, but its comparative value relative to established regional techniques remains uncertain. This systematic review and meta-analysis of randomized controlled trials (RCTs) assessed postoperative pain and opioid use with ESPB versus no regional block/standard care and versus active regional analgesic techniques.Methods PubMed, Scopus and Web of Science were searched from database inception to January 2026. Two reviewers independently screened records, extracted data and assessed risk of bias using the revised Cochrane Risk of Bias 2 tool. Comparator-stratified random-effects meta-analyses used standardized mean differences (SMDs) for pain and opioid outcomes using R software (v. 4.5.2). Certainty was assessed with GRADE.Results Systematic search identified 23 RCTs (n = 1401). Versus no block/standard care, ESPB was associated with statistically lower pain at 2 h (SMD = −1.08, 95% CI: −1.91 to −0.24; I2 = 84.4%), 4 h (SMD = −2.72, 95% CI: −4.30 to −1.14; I2 = 93.5%), 6 h (SMD = −1.19, 95% CI: −1.73 to −0.65; I2 = 85.2%) and 48 h (SMD = −0.58, 95% CI: −1.04 to −0.12; I2 = 63.5%), but not at 12 or 24 h. The 48-h finding was leave-one-out sensitive. Head-to-head effects were predominantly non-significant and selected timepoints favored active comparators. At 24 h, opioid consumption was lower versus no block (SMD = −1.30, 95% CI: −2.16 to −0.45; I2 = 91.9%), but marked Doi-plot asymmetry was present. Postoperative nausea and vomiting were less frequent (RR = 0.55, 95% CI: 0.35 to 0.88; I2 = 0%), although the result was sensitivity-analysis fragile. Certainty was generally low or very low.Conclusion Current randomized evidence suggests that ESPB may improve early postoperative pain scores compared with no regional block, but pooled estimates are limited by marked clinical and statistical heterogeneity. No consistent superiority over established regional techniques has been demonstrated. ESPB is therefore best considered a possible alternative within multimodal analgesia rather than a replacement for targeted hip blocks.Protocol registration www.crd.york.ac.uk/prospero/ identifier CRD420261372476.