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Background and Aims Meningomyelocele (MMC), a prevalent neural tube defect, necessitates prompt surgical correction and careful postoperative pain management, especially in pediatric populations. Traditional analgesic approaches rely heavily on opioids, which carry significant risks such as respiratory depression and delayed recovery. Ultrasound-guided erector spinae plane block (ESPB) is a relatively novel regional anesthesia technique that offers opioid-sparing, targeted analgesia. This study aimed to assess the analgesic efficacy of ESPB in children undergoing MMC repair surgery.Methods A prospective, randomized controlled study was conducted at King George’s Medical University, Lucknow, from June 2023 to December 2024. Seventy pediatric patients (aged 2 to 36 months) scheduled for elective MMC surgery were randomly divided into two groups: Group B received general anesthesia with ESPB using 0.5 ml/kg of 0.25% bupivacaine, while Group C received general anesthesia alone. The primary outcome was postoperative pain intensity measured by the FLACC scale at intervals of 0, 1, 2, 4, 6, 12, and 24 hours after extubation. Secondary outcomes included intraoperative fentanyl consumption, time to first rescue analgesia, intraoperative hemodynamic changes, and incidence of adverse events.Results Group B exhibited significantly lower FLACC scores at all assessed postoperative intervals compared to Group C (p<0.05), indicating superior analgesia. Intraoperative fentanyl consumption was significantly reduced in Group B (p<0.001), and the time to first rescue analgesia was longer compared to Group C (p<0.001). Hemodynamic parameters, particularly heart rate and mean arterial pressure, were more stable in the ESPB group. No adverse effects or complications related to the ESPB technique were observed throughout the study.Conclusions Ultrasound-guided ESPB is a safe and effective technique for providing postoperative analgesia in pediatric patients undergoing meningomyelocele surgery. It significantly reduces opioid use, enhances postoperative comfort, and maintains hemodynamic stability. ESPB should be considered a valuable component of multimodal analgesia protocols in pediatric neuro-surgical care.