A case of advanced ankylosing spondylitis involving the entire spine posted for posterior thoracolumbar fixation in view of unstable chance fracture at T12 - L1 level. Patient had fixed rigidity of the cervical spine with minimal rotational movement and inability to lie supine with recent ICU admission for acute pulmonary oedema due to severe plasmodium falciparum infection, post optimisation in ICU patient was posted for thoracolumbar fixation from T8 to L4 level. An awake fiberoptic guided intubation was performed and case was done under total intravenous anaesthesia in the prone position. Intraoperative neuromonitoring (SSEP/MEP) done to rule out neurological damage during surgery and positioning. Considering prolonged surgery and difficult airway postoperatively, patient was electively ventilated and extubated uneventfully within 24 hours without any fresh neurological injury.
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