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Background and Aims 74-year-old woman with amyotrophic lateral sclerosis (ALS) with worsening symptoms over recent months, including relative immobility, slurring of speech, facial palsy, and mildly impaired swallowing/ dribbling presenting with an ankle fracture. AIMS: The primary objective was to prevent further neurological deterioration during the perioperative period while ensuring stability and pain management

Methods Following evaluation, a decision was made to combine spinal anesthesia (SA) with popliteal sciatic and adductor canal blocks. High-risk consent was obtained from both the patient and family, outlining the relative risks of GA versus SA. 2.8ml of isobaric bupivacaine 0.5% without OPIOID was used for SA, while ultrasound-guided administration of 0.25% levobupivacaine (15ml each) was used for the nerve blocks. The patient was positioned on an Oxford pillow to mitigate reflux or aspiration, and no sedation was administered. The procedure proceeded without complications

Results Postoperatively, the patient was pain-free, awake, and comfortable. The nerve blocks facilitated a comfortable recovery without the need for strong opiates. Deep vein thrombosis prophylaxis commenced six hours post-surgery, and the patient managed well on oral analgesics. Vigorous chest physiotherapy, including incentive spirometry, ensured a complication-free recovery

Conclusions ALS poses challenges in anesthesia management due to its progressive motor neuron degeneration. Debate persists regarding the choice of anesthesia, with spinal anesthesia potentially exacerbating neurological symptoms and GA carrying risks of respiratory depression and aspiration. Individualized decision-making is paramount. In this case, a low-dose opioid-free SA combined with peripheral nerve blocks yielded an uneventful recovery, highlighting the importance of tailored approaches in ALS patients