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Background and Aims Enhancing recovery after cardiac surgery is a major goal of regional anesthesia. The erector spinae plane (ESP) block is gaining traction in this field, but the impact of perineural dexamethasone—particularly when combined with serial pain assessments at rest and movement—remains unexplored. Objective: To evaluate whether dexamethasone as an adjuvant to ESP block improves early recovery markers, including mechanical ventilation duration and dynamic pain scores, in patients undergoing coronary artery bypass grafting (CABG).Methods In this double-blind, randomized controlled trial, patients received bilateral ESP block with 0.2% ropivacaine ± 8 mg perineural dexamethasone. Pain was rigorously assessed at rest and during movement over 48 hours using NRS/VAS scales. Other endpoints included opioid use and extubation time.Results Among 43 patients (21 control, 22 dexamethasone), static and dynamic pain scores were low and comparable. However, the dexamethasone group exhibited a significantly shorter time to extubation (751 ± 333 vs. 848 ± 236 min, p = 0.041). This earlier ventilatory liberation occurred despite similar opioid requirements, suggesting improved pain tolerance during active respiratory effort. No block-related complications were reported.Conclusions This is the first study to integrate perineural dexamethasone with dynamic pain assessments following ESP block in cardiac surgery. Although acute pain scores were similar, dexamethasone significantly accelerated extubation—highlighting its role in enhancing recovery. These findings advocate for its inclusion in ERACS pathways and warrant multicenter validation.