BACKGROUND The aim of this study was to determine whether an elevated lateral recumbent position, compared to regular lateral recumbent position, may reduce the number of needle passes and attempts required for success subarachnoid puncture in spinal aesthesia before surgery in elderly patients with hip fractures. MATERIAL AND METHODS This was a randomized controlled interventional study in Beijing Jishuitan Hospital. Patients older than 65 years of age with hip fracture orthopedics who were planned to receive subarachnoid block in the lateral recumbent position before surgery were enrolled. The eligible patients were randomly allocated into the experimental group, in which a lateral recumbent position with head and chest elevated 30° was taken during subarachnoid puncture. In the control group, subarachnoid puncture was performed in the lateral recumbent position. The main outcome was the numbers of needle passes required for a success puncture. Other outcomes included success rate in different numbers of attempts, patients reported discomfort score, and complications. RESULTS A total of 90 patients were enrolled, with 45 patients in each group. The number of needle passes (2.00 versus 3.00, P=0.001) and the number of attempts (1.00 versus 2.00, P<0.001) required for a successful subarachnoid puncture were significantly less in the experimental group than in the control group. Patients in the experimental group also had lower discomfort scores. The procedure process, including overall times needed for puncture, anesthesia, and surgery did not show differences between the 2 groups. Complications were few and similar between the 2 groups. CONCLUSIONS An elevated lateral recumbent position during the subarachnoid puncture in spinal anesthesia significantly reduced the needle pass numbers needed for success dural puncture, and reduced discomfort in elderly patients with hip fractures.