Lumbar puncture (LP) may be unsuccessful clinically, prompting image-guided LP by radiologists. Objective. To investigate the utility of ultrasound (US) in diagnosing the cause of failed LP and in guiding LP.Neonates and infants referred for image-guided LP underwent spine US of the thecal sac. When indicated, image-guided LP was performed.Forty-seven evaluations and interventions were performed in 32 patients. All patients were initially evaluated after failed blind LP attempts. Twenty-three of the initial US studies showed intrathecal and/ or epidural echogenic hematoma, which obliterated the CSF space; 5 showed minimal fluid, and 4 had normal examinations. LP was deferred or cancelled in 14 cases based upon initial US findings. Image-guided LP was performed 32 times in 19 patients. US guidance was used in 26, fluoroscopy in 3, and fluoroscopy with US assistance in 3. Using US, LP was performed in 9 patients with no visible CSF: 2 samples were sufficient for culture only. Six patients had minimal CSF US: 4 provided usable CSF samples. Clear CSF space was seen in 11: all had successful LP.US can disclose the cause of failed LP, can help determine whether or not to intervene further, and can provide guidance for LP.