Fluoroscopy-guided intrathecal lumbar drain placement in severe post-polio spinal deformity: A case report

Spontaneous cerebrospinal fluid (CSF) rhinorrhoea undergoing endoscopic endonasal repair often requires intraoperative intrathecal lumbar drain (ITLD) placement for fluorescein-assisted fistula localisation and postoperative CSF diversion. Severe spinal deformity can render conventional landmark and ultrasound-guided neuraxial access impossible. We describe a 45-year-old female with post-polio thoracolumbar scoliosis and vertebral rotation undergoing endoscopic repair of a cribriform plate CSF leak, in whom both landmark and ultrasound-guided ITLD placement failed because of absent acoustic windows. Fluoroscopy revealed an apparent lateral image on the standard antero-posterior projection, reflecting near 90-degree axial vertebral rotation.A patient-specific 30-degree oblique C-arm angulation restored a functional antero-posterior-equivalent view, enabling successful catheter placement after fine-needle confirmation. Fluorescein-guided endoscopic repair was subsequently completed uneventfully, with no neurological or CSF-leak-related complications. This case highlights a reproducible, stepwise rescue algorithm-landmark, ultrasound, and patient-tailored fluoroscopic oblique angulation for safe neuraxial access in severely deformed spine, applicable across diverse difficult neuraxial access scenarios.