THE TRADE-OFF BETWEEN ANALGESIC POTENCY AND PROCEDURAL SAFETY: ERECTOR SPINAE PLANE BLOCK VERSUS THE GOLD-STANDARD THORACIC PARAVERTEBRAL BLOCK IN UNIPORTAL AND MULTIPORTAL VIDEO-ASSISTED THORACOSCOPIC SURGERY — A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS AND PRIMARY STUDIES

Abstract

Introduction: Uniportal and multiportal video-assisted thoracoscopic surgery (VATS) reduce surgical trauma, yet moderate-to-severe acute pain remains common and predisposes to pulmonary complications and chronic postsurgical pain (CPSP). The thoracic paravertebral block (TPVB) is regarded as the regional "gold standard", whereas the erector spinae plane block (ESPB) is technically simpler and theoretically safer. Whether ESPB trades analgesic potency for procedural safety has not been quantified jointly. We aimed to compare the analgesic efficacy, opioid-sparing effect, recovery quality and procedural safety of ESPB versus TPVB, hypothesising that TPVB provides superior early analgesia, that both blocks converge beyond the early period, and that ESPB carries fewer block-related complications.

Methods: The study strictly adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines were searched from January 2011 to September 2026, supplemented by citation searching. Randomised controlled trials (RCTs), comparative cohorts and comparative case series directly comparing ESPB with TPVB in minimally invasive thoracic surgery were eligible. Risk of bias was assessed with RoB 2 and the Newcastle–Ottawa Scale. Random-effects (DerSimonian–Laird) meta-analyses generated mean differences (MD), standardised mean differences (SMD) and risk ratios (RR); rare block-related complications were pooled with the Peto odds ratio (OR). Certainty was graded with GRADE.

Results: Twenty-seven studies (24 RCTs, 3 cohorts; 2,015 participants; 26 thoracic studies, n = 1,960) were included and 20 contributed to 21 meta-analyses. TPVB produced lower rest pain at 0–2 h (MD 0.41, 95% CI 0.02–0.81; I² = 84%), an advantage below the 1-point minimal clinically important difference that disappeared from 6 h onward (24 h: MD 0.13, −0.20 to 0.46; 48 h: MD −0.08, −0.24 to 0.09). Dynamic pain did not differ at any time point. Twenty-four-hour opioid consumption showed a borderline opioid-sparing effect of TPVB (SMD 0.35, −0.00 to 0.71; p = 0.051), significant in adults only (SMD 0.41, 0.04–0.79). Rescue analgesia (RR 1.21, 0.83–1.77), PONV (RR 1.00, 0.75–1.34), hypotension (RR 0.60, 0.18–1.97), QoR-15 (MD 1.19, −4.80 to 7.17), length of stay (MD −0.13 days, −0.38 to 0.12) and CPSP (RR 0.96, 0.68–1.34) were comparable. Block-related complications (pneumothorax, pleural puncture, haematoma, unintended epidural spread) were markedly less frequent with ESPB (1/276 vs 15/270; Peto OR 0.15, 0.05–0.40; p < 0.001).

Discussion: The ESPB–TPVB relationship is a time-dependent trade-off: TPVB buys a small, short-lived gain in early somatic analgesia and possibly opioid sparing at the price of a roughly seven-fold higher odds of block-related complications, whereas analgesia, recovery quality and long-term pain converge thereafter. Certainty was low to very low for most efficacy outcomes and moderate for safety, length of stay and CPSP.

Conclusion: ESPB is a safer, analgesically comparable alternative to TPVB for (uniportal) VATS beyond the first postoperative hours. TPVB may be reserved for patients in whom maximal early analgesia is prioritised and procedural risk is acceptable.