Background and Aims Kagami ogata syndrome (KOS)patients present with craniofacial dysmorphism, thoraco abdominal abnormalities, and kyphoscoliosis.The choice of regional anesthesia poses a real challenge as the reliance on the usual regional anesthetic techniques including lumbar epidural, paravertebral, fascial plane blocks, and landmark caudal blocks can be very challenging.

Methods We elected to perform a real time ultrasound (US) guided caudal epidural block (CEB) in a patient with a medically challenging spine anatomyto identify the midline, depth, and level with spread of local anesthesia into the caudal epidural space.

Conclusions This report should encourage pediatric anesthesiologists to familiarize themselves with ultrasound guided caudal blocks as certain situations will dictate such a need.