When palpation fails: fluoroscopy-assisted localization using a radiopaque grid for neuraxial puncture in a 96-year-old woman undergoing emergency hip fracture surgery– a case report

Degenerative spinal changes in older adults can make surface landmarks difficult to palpate. Preprocedural ultrasound is generally the preferred imaging adjunct because it avoids ionizing radiation, but local equipment availability and operator expertise vary. We report a context-specific use of fluoroscopy with a radiopaque grid after palpation failed in a 96-year-old woman undergoing emergency hip-fracture fixation. A 96-year-old woman with a left intertrochanteric femoral fracture underwent spinal anesthesia. Because conventional palpation did not identify a definite lumbar interspace, a sterile radiopaque grid was placed on the lower back and an anteroposterior image was obtained with a mobile C-arm. The L4-L5 interspace corresponded to grid coordinate F7. Localization from grid application to skin marking required 120 s; fluoroscopy time was 20 s and the dose-area product was 43.85 µGy·m². A 25-gauge Whitacre needle entered the intrathecal space through one skin puncture without needle redirection. Intrathecal 0.5% isobaric ropivacaine 12.5 mg produced a T10 sensory block. No vasopressor was required, and no neurologic complication was observed during 48 h of follow-up. In this single patient, fluoroscopic localization with a radiopaque grid identified the intended L4-L5 interspace and was followed by successful spinal needle placement after palpation failed. This observation supports feasibility only and does not establish superiority, reproducibility, dose safety, or control of intrathecal anesthetic spread. Where trained ultrasound guidance is unavailable and fluoroscopy can be used within local workflow and radiation-safety protocols, the technique may be considered as a rescue localization option.