Ninety elderly patients scheduled for hip fracture surgery were randomized to undergo spinal anesthesia via a subarachnoid puncture delivered in the lateral recumbent position (n=45) or an elevated lateral recumbent position with head and chest at 30° (n=45). The primary outcome of interest included the number of needle passes required for a successful puncture. Secondary outcomes of interest included the incidence of complications (i.e. radicular pain, paresthesia, and blood in the spinal needle), postoperative pain measured on the numeric rating scale (NRS), patient satisfaction using a discomfort scoring system, time for identifying landmarks, total operative time, time for spinal anesthesia, success rate of the first needle-pass during the first puncture attempt, success rate of dural puncture within 2 passes, success rate of dural puncture at the first attempt, and success rate of dural puncture within 2 attempts. Other outcomes measured included the ultrasound image quality, number of attempts, intrathecal ropivacaine dosage, depth of intrathecal space, distance from midline to paramedian needle insertion point, peak sensory dermatome level, and interspace level used for dural puncture. The results revealed that the number of needle passes required for a successful puncture (p=0.001) and number of attempts (p<0.001) were both statistically significantly reduced in the elevated lateral position (ELP). Furthermore, the incidences of successful dural puncture at the first pass (p=0.016), successful dural puncture within 2 passes (p=0.002), successful dural puncture at the first attempt (p=0.001), successful dural puncture within 2 attempts (p=0.030) were all favored in the ELP group. All other outcomes were similar between the two groups, with no statistical significant differences observed (p>0.05 for all).