Background and Goal of Study: Spinal anaesthesia(SA) has been the technique of choice for femur fracture surgery in elderly patients. Usually SA is performed using the midline approach, but it is technically difficult where adequate flexion for proper positioning is not possible,such as patients with femur fracture.Some authors have recommended paramedian approach because this approach does not require flexed position as in midline approach.The goal of this study was to determine which of approaches of SA should be preferred as first choice in elderly patients for femur proximal fracture surgery. 
Materials and Methods: We prospectively studied 88 patients aged >65 years, who underwent open repair of a femur proximal fracture.These patients were randomized to receive SA either with the midline approach (group M, n=44) or paramedian approach (group PM, n=44).In both groups the SA was given with 25 gauge spinal needle in sitting position at L3-L4 interspace.For every patient we considered the: average age, success rate in first attempt, number of punctions, and failure. 
Results and Discussion:The mean age in the M group was 71.4 and in the PM group 73.2 years.First attempt success rate was 27 (61.3%) in M group and 40 (90.9 %) in PM group .More than one attempt was required in 21 patients (47.7%) in the M group, and 6 patients (13.6%) in the PM group. In three cases of M group, spinal puncture was impossible and were successful with the paramedian approach. In both the groups ,there was no failure of spinal anesthesia. 
Conclusion(s): In conclusion, paramedian approach is  better approach for SA and should be routinely used as first choice in elderly patients with proximal femur fracture where adequate flexion for proper positioning for midline approach is not possible.

Paramedian approach: a better technique for spinal anaesthesia in elderly patients for femoral proximal fracture surgery