This systematic review aimed to compare the efficacy and safety of thoracic epidural block (TEB) and thoracic paravertebral block (TPB) for managing postoperative pain following thoracotomy for pulmonary procedures.

A comprehensive search of PubMed, Embase, Web of Science, and Google Scholar identified randomized controlled trials (RCTs) published prior to April 10, 2024. Studies were eligible if they compared TEB and TPB in adult patients undergoing thoracotomy for pulmonary procedures and reported outcomes on postoperative pain, opioid consumption, hemodynamic parameters, or complications. Two reviewers independently screened studies, extracted data, and assessed quality using the Cochrane Risk of Bias tool. The review adhered to PRISMA guidelines. From 1,114 records screened, 7 RCTs comprising 429 patients met the inclusion criteria. TEB demonstrated superior pain relief in the immediate postoperative period, particularly when continuous infusions with opioids were utilized. TPB, however, provided greater hemodynamic stability, with significantly lower rates of hypotension and more stable mean arterial pressure and heart rate during the first 24 h. Beyond 24 h, both techniques offered comparable pain relief and opioid consumption. While the incidence of nausea, vomiting, and urinary retention was similar between groups, TPB was associated with fewer respiratory complications.

Both TEB and TPB are effective for postoperative pain management following thoracotomy, each with distinct advantages. TEB provides optimal early pain control, making it suitable for patients with significant early postoperative pain. TPB, with its superior hemodynamic profile, is better suited for patients at risk of hypotension or cardiovascular instability. Tailoring analgesic strategies to patient-specific needs can optimize outcomes. Future large-scale RCTs are necessary to confirm these findings across broader thoracic surgical populations.

This review was registered with PROSPERO prior to initiation (Registration Number: CRD42024578768).