Background: Use of thoracic epidurals for intra‑ and post‑operative analgesia for open abdominal surgeries has exponentially increased over the last decade. Spinal anaesthesia is used a landmark – guided midline approach, in these absent, indistinct or distorted in the presence of obesity, previous spinal surgeries, deformities, or degenerative changes associated with ageing. In the present study evaluates the efficacy of real‑time ultrasound (RUS)‑guided paramedian approach, and pre‑procedure ultrasound (PUS) landmark‑guided paramedian approach in obese persons. Methods: This is a Prospective Randomized Double-Blind Study conducted in Akash Institute of Medical Sciences and Research centre. Total 50 subjects (Group A – 25, Group A – 25). All the subjects included after informed consent, Along with Chest X- ray and ECG-for patients over 40 years of age. The primary end point was to attain a successful lumbar puncture. Variables like the number of attempts, the number of passes, the time taken for identifying landmark(s), and time for a successful lumbar puncture(s) were secondary end points and were recorded in both the groups. Results: This study was evaluated In real‑time ultrasound (RUS)‑guided paramedian approach, and pre‑procedure ultrasound (PUS) landmark‑guided paramedian approach in obese patients. There is a statistically high significant difference in PUS group than RUS Group. A P value < 0.002 is the statistically in between 2 groups. Conclusion: the space identification and number of attempts, passes and time consuming in pre procedure ultrasound when compared to real time ultrasound. This study suggest real time ultrasound is good for identification of space.