Introduction: Spinal anesthesia is a challenging procedure, especially in the elderly population. The ultrasound-guiding is reported to provide additional information to facilitate the procedure. To date, there has been no meta-analysis in this field. The study aimed to systematically review and compile a meta-analysis to examine the efficacy of ultrasound-guiding compared to the palpation of anatomical landmarks in spinal anesthesia procedures performed for elderly patients. Methods: A systematic literature search from PubMed, Cochrane Library, and Clinicaltrial. gov was conducted to find randomized controlled trials study which comparing ultrasound-guiding and anatomical landmarks of spinal anesthesia in geriatric population. Meta-analysis was performed according to PRISMA guidelines. The continuous and dichotomous data, respectively, are using the calculation of mean differences with inverse variance, and Odds Ratio using the Mantel-Haenszel method. Results: Four studies with a total of 436 patients met the criteria. Based on the analysis, landmark-guided have more number of attempts [IV-0.66, 95%CI=(-1.20, –0.13), p=0.01], and higher number of passes [IV-1.43, 95%CI=(-2.68, –0.18), p=0.03], compared to ultrasound-guided. Ultrasound-guided has success rate of first attempt [OR 3.37, 95%CI=(1.17, 9.73), p=0.02], and success rate of first passes [OR 3.60, 95%CI=(1.39, 9.29), p=0.008], which is significantly higher when compared to landmark-guided. Ultrasound-guided had a longer duration of procedure than landmark-guided which was statistically significant [IV 59.14, 95%CI=(4.58, 113.70), p=0.03]. Conclusion: The ultrasound-guiding for spinal anesthesia in elderly is recommended. This approach should be considered as the standard of care, given its potential to improve technical efficacy in conducting spinal anesthesia in particular populations.