<![CDATA[Summary Background: Postoperative pain after video-assisted thoracoscopic surgery (VATS) remains clinically important despite its minimally invasive nature. Thoracic epidural analgesia (TEA) is an established analgesic technique but may be limited by neuraxial-related adverse effects and catheter-related interventions. Continuous erector spinae plane block (ESPB) has emerged as a less invasive alternative. Methods: This systematic review compared the efficacy and safety of continuous ESPB versus TEA for postoperative analgesia after VATS. This review followed PRISMA 2020 guidelines and was registered in PROSPERO (CRD420261418508). PubMed/MEDLINE, Scopus, Cochrane CENTRAL, and ClinicalTrials.gov were searched from inception to 10 June 2026. Eligible studies were randomized controlled trials directly comparing continuous ESPB with TEA in adult VATS patients. Risk of bias was assessed using the Cochrane RoB 2 tool, and findings were synthesized narratively. Result: Four randomized controlled trials involving 301 analyzed participants met the eligibility criteria. TEA generally provided better early analgesia and lower rescue opioid consumption, particularly for dynamic pain during coughing or movement. Continuous ESPB provided acceptable analgesia in selected studies and was associated with fewer neuraxial-related adverse effects, including hypotension, pruritus or itching, urinary retention, and catheter-related interventions. Conclusions: Current evidence is insufficient to determine whether continuous ESPB is superior to TEA after VATS. Continuous ESPB may be considered a potential alternative when avoidance of neuraxial-related adverse effects is important, but no firm clinical recommendation can be made. Keywords: Erector spinae plane block; Thoracic epidural analgesia; Video-assisted thoracoscopic surgery; Postoperative pain; Randomized controlled trial ]]>
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