114 elderly patients scheduled for a hip fracture surgery were randomized to receive spinal anesthesia that was ultrasound-assisted (n=57) or with real-time ultrasound-guidance (n=57). The primary outcome of interest was first-attempt success rate. Secondary outcomes of interest included first-pass success rate, time to perform anesthesia, patient satisfaction, procedural difficulty, block characteristics, and adverse events. The results found real-time ultrasound-guidance to have a lower rate of success at first-attempt and first-pass. Moreover, the time to perform anesthesia was longer and was more difficult to perform in the real-time ultrasound-guidance group, and led to lower patient satisfaction and a significant amount of crossover to ultrasound-assisted anesthesia.