BACKGROUND Inguinal hernia is a common disease in preterm infants necessitating surgical repair. Despite the increased risk of postoperative apnea in preterm infants, the procedure was conventionally performed under general anesthesia. Recently, regional anesthesia approaches, including spinal and caudal blocks have been proposed as safe and efficient alternative anesthesia methods in this group of patients. The current study evaluates awake caudal and spinal blocks in preterm infants undergoing inguinal hernia repair. MATERIALS AND METHODS In a randomized clinical trial, 66 neonates and infants (weight <5 kg) undergoing inguinal hernia repair were recruited in Tabriz Teaching Children Hospital during a 12-month period. They were randomly divided into two equal groups; receiving either caudal block by 1 ml/kg of 0.25% bupivacaine plus 20 μg adrenaline (group C) or spinal block by 1 mg/kg of 0.5% bupivacaine plus 20 μg adrenaline (group S). Vital signs and pain scores were documented during operation and thereafter up to 24 h after operation. RESULTS Decrease in heart rate and systolic blood pressure was significantly higher in group C throughout the study period (P < 0.05). The mean recovery time was significantly higher in group S (27.3 ± 5.5 min vs. 21.8 ± 9.3 min; P = 0.03). Postoperative need for analgesia was significantly more frequent in group S (75.8% vs. 36.4%; P = 0.001). Failure in anesthesia was significantly higher in group S (24.4% vs. 6.1%; P = 0.04). CONCLUSION More appropriate success rate, duration of recovery and postoperative need of analgesics could contribute to caudal block being a superior anesthesia technique compared to spinal anesthesia in awaked preterm infants undergoing inguinal hernia repair.