Abstract

Background and Objectives: Spinal anesthesia in elderly patients presents unique challenges due to anatomical changes, comorbidities, and technical difficulties. This prospective randomized controlled study aimed to compare the efficacy and safety of ultrasound-guided (USG) versus landmark-guided techniques for paramedian spinal anesthesia in elderly patients. 
Methods: A total of 120 patients aged 65 years and above, scheduled for lower limb and lower abdominal surgeries under spinal anesthesia, were randomly allocated into two groups: Group U (USG-guided, n=60) and Group L (landmark-guided, n=60). Primary outcomes included first-pass success rate, total procedure time, and number of attempts. Secondary outcomes evaluated patient comfort scores, hemodynamic stability, block characteristics, and complications. 
Results: The USG-guided group demonstrated significantly higher first-pass success rates (88.3% vs 66.7%, p<0.001), reduced total procedure time (8.2±2.1 vs 11.4±3.8 minutes, p<0.001), and fewer total attempts (1.2±0.4 vs 1.8±0.9, p<0.001) compared to the landmark-guided group. Patient comfort scores were significantly better in the USG group (7.8±1.2 vs 6.1±1.8, p<0.001). The USG group showed superior block characteristics with faster onset times and more predictable sensory levels. Hemodynamic parameters remained more stable in the USG group with fewer episodes of hypotension (8.3% vs 21.7%, p=0.045). 
Conclusion: Ultrasound guidance significantly improves the success rate, reduces procedure time, and enhances patient comfort during paramedian spinal anesthesia in elderly patients while maintaining excellent safety profiles