Aims This systematic review evaluates the efficacy and safety of intrathecal opioids compared with epidural analgesia, patient-controlled analgesia (PCA), or intrathecal placebo following elective laparoscopic colorectal resection within enhanced recovery after surgery (ERAS) pathways. Methods A systematic review was conducted in accordance with PRISMA and Cochrane guidelines and registered prospectively with PROSPERO; Registration ID: CRD420251183274). MEDLINE was searched from inception to December 2025. Eligible studies compared single-shot intrathecal opioids (with or without local anaesthetic) with thoracic epidural analgesia, intravenous PCA, or intrathecal placebo in patients undergoing laparoscopic colorectal resection. Primary outcomes were postoperative pain and opioid consumption; secondary outcomes included recovery parameters, length of stay, and adverse events. Results Four randomised controlled trials published between 2011 and 2024, enrolling 269 patients, met inclusion criteria. Across all studies, intrathecal opioid-based analgesia consistently reduced early postoperative pain scores and significantly lowered systemic opioid requirements compared with PCA or placebo. No study showed a significant reduction in length of hospital stay or incidence of postoperative ileus. Adverse events were generally mild; pruritus occurred more frequently with intrathecal opioids, while serious complications, including respiratory depression, were rare. Conclusion In ERAS-aligned laparoscopic colorectal surgery, low-dose intrathecal opioid administration provides effective analgesia and reduces postoperative opioid consumption without increasing major complications. Intrathecal opioids represent a viable alternative to epidural analgesia and PCA; however, larger, multicentre trials are required to define optimal dosing and long-term outcomes.