Introduction. The anesthetic efficacy of the ultrasound-guided rhomboid intercostal block (RIB) in alleviating postoperative pain has been well concerned. This study aims to compare the effectiveness between ultrasound-guided RIB and paravertebral block (PVB) in alleviating acute pain following video-assisted thoracic surgery. Methods. It was a prospective, randomized, double-blinded clinical trial involving 132 patients with video-assisted thoracic surgery divided into three groups: the general anesthesia (GA) group, RIB group, and PVB group on T5 vertebra, using 0.4% ropivacaine at 3 mg/kg, registered in the Chinese Clinical Trial Registry (ChiCTR2100054057, “https://www.chictr.org.cn”). The visual analogue scale (VAS) scores at rest and cough during 48 h postoperatively and the postoperative consumption of pain rescue were the primary outcomes, and the QoR15 score 48 h postoperatively, the usage of opioids during and after operation, and nerve block-related complications were the secondary outcomes. Demographic characteristics, surgery characteristics, and primary outcomes between the groups were compared. Results. A total of 120 eligible patients were recruited, including 40 in each group. Baseline and surgery characteristics between the groups were comparable (all p > 0.05 ). The PVB and RIB groups were better than the GA group in the primary and secondary outcomes ( p < 0.05 ). The static VAS score, QoR15 score, and block-related complications within 48 hours after surgery were better in the RIB group than in the PVB group ( p < 0.001 ). Conclusion. Both PVB and RIB can provide adequate analgesia and accelerate the recovery of patients. Compared with PVB, RIB has a better analgesic effect, especially to avoid paravertebral pain caused by block, and the operation of RIB is more straightforward and the safety is higher.