The purpose of this study was to evaluate the technical success and complication rates of image-guided lumbar puncture (IGLP) and to evaluate for differences in approach employed to help establish the optimum technique. A retrospective search of the hospital picture archiving and communications system was performed to identify all IGLPs that had taken place over a 5-year period. Radiology reports and the electronic medical record were examined to identify technical parameters and complications associated with each procedure. The technical success rate was 96% (219/228). 69.4% ( = 161) had a previously failed bedside attempt. The rate of complications was 0.01% ( = 2). No major complications were observed. There was no difference in the rates of failure (2.4% vs  3.6%, = 0.68) or complications (0.008% vs  0.012%, = 1) between interlaminar and interspinous approaches. IGLP is a safe procedure with a high rate of technical success. Where a difficult bedside attempt is anticipated, it is reasonable to forego this and proceed directly to IGLP. This paper helps to confirm what is already assumed about a common radiological procedure. This is important as there has been a shift from bedside technique to most lumbar punctures being performed via image guidance.