Analgesic efficacy and safety of erector spinae plane block after sternotomy and minimally invasive cardiac surgery: A systematic review and Meta-analysis of randomized trials

BACKGROUND: The erector spinae plane block (ESPB) is increasingly used for analgesia in cardiac surgery, but its effectiveness across surgical approaches remains uncertain. We aimed to evaluate the analgesic efficacy, recovery effects, and safety of ESPB in adult cardiac surgery, with analyses stratified by surgical approach (median sternotomy versus minimally invasive cardiac surgery [MICS]). METHODS: We searched MEDLINE, Embase, CENTRAL, and Scopus (January 2016-June 2025) for randomized controlled trials (RCTs) comparing ultrasound-guided ESPB with standard systemic analgesia in adults undergoing cardiac surgery. This PRISMA-compliant review (PROSPERO: CRD42024570340) used random-effects meta-analyses with Hartung-Knapp adjustment. Risk of bias was assessed using RoB 2, and certainty of evidence using GRADE. The primary outcome was postoperative pain within 24 h. Secondary outcomes included opioid consumption, time to extubation, ICU and hospital length of stay, and complications. RESULTS: > 85% for most outcomes), and wide prediction intervals crossed the null, suggesting that effects may vary substantially across clinical settings. In the MICS subgroup (4 RCTs, n = 252), no clear statistically significant or clinically meaningful benefits were detected for most outcomes in pain, opioid use, or recovery outcomes. CONCLUSION: Low- to very-low-certainty evidence suggests that ESPB is associated with modest improvements in early pain and recovery after median sternotomy; however, very high heterogeneity and wide prediction intervals indicate that effects may vary substantially between centers. In contrast, no clear benefit was demonstrated within ERAS-optimized MICS pathways, and findings in this subgroup remain preliminary.