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Background and Aims A 75-year-old female patient with a history of arterial hypertension, managed with ACE inhibitors, underwent posterior thoracic and lumbar spinal fusion (T11-L5) for lumbar spinal stenosis (L1-L4). General anesthesia was induced with propofol 1%, rocuronium, and fentanyl, while maintenance was achieved with sevoflurane and remifentanil, guided by bispectral index monitoring to maintain an appropriate anesthetic depth. The patient remained hemodynamically stable throughout the 3-hour operation.Methods Before emergence from general anesthesia and extubation, a bilateral ultrasound-guided Erector Spinae Plane (ESP) Block was performed at T8 level with the patient in prone position. A single shot of 20 ml ropivacaine 0.375% and 50 mcg clonidine was implemented on each side. Afterwards, the patient was transferred to the postanesthetic care unit and was discharged 60 minutes later, as her cardiopulmonary status was stable, accompanied by a low pain score (VAS=2/10) postoperatively.Results Around 80 minutes after the patient‘s admission to the Orthopedic Department, significant hypotension was observed, with a systolic blood pressure of 68 mmHg. Physical examination revealed no sensory, motor, or reflex abnormalities in the lower extremities, nor any other signs of local anesthetic toxicity. Laboratory tests and imaging studies were also within normal range. Suspecting ESP block-induced hypotension, continuous hemodynamic monitoring was initiated, along with the administration of 1000 ml Ringer’s lactate solution containing 12 mg of noradrenaline, in order to maintain systolic blood pressure above 110 mmHg. Subsequently, the infusion rate was gradually reduced, and after 48 hours the patient was stabilized hemodynamically, requiring no analgesic regimen.Conclusions ESP block-induced hypotension was attributed to the spread of local anesthetic into the paravertebral and epidural space, along with the administration of clonidine and high dose of local anesthetic. Hence, we advocate the infusion of dilute local anesthetic solutions and advise against the use of clonidine in elderly patients receiving antihypertensive therapy.