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Background and Aims Patients with spina bifida undergoing spinal anesthesia are at increased risk of further neurologic injury due to altered spinal anatomy. Meanwhile, concomitant scoliosis heightens the risk of restrictive lung disease and pneumonia. While research has been focused on managing secondary co-morbidities associated with spina bifida, limited attention has been given to the perioperative care of its increasing adult population. We aim to report the safe use of ultrasound-assisted neuraxial anesthesia in a patient with repaired spina bifida, scoliosis, and a predicted difficult airway.Methods This case presents a 36-year-old female with repaired spina bifida, a history of multiple shunt revisions, scoliosis, short and thick neck, limited neck range of motion, and inadequate thyromental distance. During admission, she was diagnosed with community-acquired pneumonia requiring supplemental oxygen and bilateral popliteal full-thickness ulcers, for which she was scheduled for debridement. Real-time ultrasonography was done to identify the L4-L5 interspace and needle trajectory. Isobaric bupivacaine was administered to avoid unpredictable cephalad spread.Results The patient tolerated the procedure well under ultrasound-assisted neuraxial anesthesia. This technique enabled safe and precise identification of distorted spinal landmarks, minimized airway manipulation, and reduced the risk of respiratory compromise associated with general anesthesia.Abstract P233 Figure 1Posterior view of patient with repaired spina bifida and thoracolumbar scoliosisAbstract P233 Figure 2Ultrasound image of the lumbar spine in transverse interspinous view, identifying the L4-L5 intrathecal spaceAbstract P233 Figure 3Return of CSF from spinal needle, confirming intrathecal placementConclusions In this report, we recommend ultrasound-assisted anesthesia as an alternative to traditional landmark-based anesthesia in cases of scoliosis. A patient-centered anesthetic plan—emphasizing preoperative optimization, hemodynamic and respiratory stability with active pneumonia, analgesia, immobility, and postoperative pain control—is critical to achieving optimal perioperative outcomes in adult patients with spina bifida.