Wacky Sports Injuries:
Spine Injuries in Surfers
Jaspal R. Singh, MD
Assistant Professor of Rehabilitation Medicine
Director of Interventional Spine
Disclosures
Jaspal R. Singh, M.D.
• Consultant- Physician’s Pharmaceutical Solutions
• Consultant- Kimberly Clark
Cases
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Surfer’s Myelopathy
Nontraumatic Myelopathy
Complete Paraplegia
Annular Tears
History
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First reported in 2004 as a series of nine cases
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Pearce; Spine 2004; Vol 29; No: 16
Surfers Myelopathy
• Atraumatic injury to the cord
• Affects first-time surfers
– Hyperextension moment in a “predisposed”
individual
• MRI shows signal change in the affected
portions of the cord
Thompson et al in 2004
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9 Cases
– 9 presented with back pain
– 8 with paraparesis
– 8 with urinary retention
– 3 with sensory disturbances
– 1 with paraplegia
2012 Review
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19 cases
15-46 yo
Novice surfers
All had lower back discomfort
10-60 minute onset of weakness and paresthesias
Within minutes of onset, unable to walk
MRI Findings
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All had hyperintense T2 signal from mid- to lower thoracic level to the conus
No segmental image
Restricted diffusion in 6/10 patients
No evidence of aortic injury
Proposed mechanism is Artery of Adamkiewicz vasospasm
Clinical Presentation
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Average age of 25
New to surfing
Initial back pain
Relatively rapid progression of neurological symptoms (<24 hours)
Reported Outcomes
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At time of discharge: 9 cases
– 3 patients had complete recovery
– 4 patients had “mild” weakness but no sensory deficits
– 3 had urinary retention
– 1 patient remained paraplegic
Proposed Mechanisms
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Hyperextension leading to ischemia?
– Watershed zones within the cord
Concussive forces of the waves?
– Less likely given the nature of the presentation
Thrombotic events?
Risk Factors
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Thin body habitus
Underdeveloped back musculature
Recent long-distance travel
Dehydration
Why Thoracic Spine
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three regions of anterior vascular supply
– (1) cervicodorsal region;
– (2) intermediate region (midthoracic area), from T4 to T7 or T8
– (3) inferior dorsolumbar region
midthoracic area is poorly vascularized
the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz
artery.
Among surfers, the technique of standing up on a surfboard is called “popping up.”
– first, pushing up one’s torso by extending both arms from a prone “paddling”
position
– second, crouching on the surfboard and sliding the legs under the torso
– third, standing to a half-rising position, which is called the “riding” position
– Insert VIDEO and PICS
– not only the continued hyperextended posture of paddling but also repetitive
mechanical stress caused by several tries of popping up may contribute to its
pathogenesis.
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thin and underdeveloped back musculature is a possible risk factor for surfer’s
myelopathy
poor stability of the spine may result in accidental overextension or overflexion
recommend that novice surfers take mandatory rest periods during surfing lessons
– (e.g., 10 mins of rest every 45 mins)
– the time of lessons should be limited (e.g., maximum of 90 mins)
– instructors be educated as to the early detection of students’ back pain
Conclusion
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Surfing is a popular sport worldwide
The etiology of surfer’s myelopathy remains enigmatic
resulting disability can be devastating
early detection and early treatment are necessary for the prevention of neurologic
deterioration.
Awareness among clinicians and surfers is desirable.
Immediate imaging (e.g., MRI with diffusion-weighted images, magnetic resonance
angiography, and computed tomographic angiography) is desirable for the further
elucidation of its pathogenesis.
Aggressive hydration, induced hypertension, and empiric corticosteroids are
recommended as acute treatments for spinal cord ischemia.
In addition, adequate rehabilitation for the neurologic deficits is indispensable.
Complete Paraplegia
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Three patients with diagnoses of surfer’s myelopathy
(24–31 yrs old; two men, one woman)
novice surfers
rapid progression of paraplegia after back pain while taking surfing lessons
Despite months of rehabilitation
– in all three patients, complete paraplegia (T9–T12) and bladder-bowel
dysfunction remained.
neurologic outcome of surfer’s myelopathy is potentially catastrophic
Complete Paraplegia Resulting from Surfer's Myelopathy. Takakura, Tomokazu; Yokoyama, Osamu; Sakuma, Fujiko; Itoh, Ryousuke; Romero,
Ray American Journal of Physical Medicine & Rehabilitation. 92(9):833-837, September 2013.
FIGURE 2
FIGURE 2 . Case 1. Midsagittal T2WI magnetic resonance
image of thoracolumbar spinal cord 4 hrs after onset.
Increased signal and mild enlargement of lower thoracic
cord to the conus medullaris are observed (arrows).
© 2013 by Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
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FIGURE 3
FIGURE 3 . Case 1. Axial T2WI magnetic resonance image
of thoracic spinal cord at T9 spine level 4 hrs after onset.
Massive increased signal of central cord, which involves
both gray and white matter, is observed (arrow).
© 2013 by Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
2
FIGURE 4
FIGURE 4 . Case 1. Midsagittal T2WI magnetic resonance
image of thoracolumbar spinal cord at day 110. Marked
atrophy of spinal cord below T11 to the conus medullaris
(arrows) are observed.
© 2013 by Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
2
FIGURE 1
FIGURE 1 . Case 1. Midsagittal T2WI magnetic resonance
image of thoracic spinal cord 4 hrs after onset. Increased
signal and mild enlargement of lower thoracic cord
below the level of T8 vertebra are observed (arrows). In
addition, dorsal-dephasing artifacts are seen in the
midthoracic cord.
© 2013 by Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
2
J Spinal Cord Med. 2007; 30(3): 288–293.
PMCID: PMC2031959 Nontraumatic Myelopathy Associated With Surfing
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Israel Avilés-Hernández, MD, Inigo García-Zozaya, MD, and Jorge M DeVillasante, MD
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Results:
A 37-year-old man developed T11 American Spinal Injury Association (ASIA) A
paraplegia shortly after surfing. The clinical history and magnetic resonance imaging
findings were compatible with an ischemic insult to the distal thoracic spinal cord. Our
patient did not have any of the proposed risk factors associated with this condition,
and, contrary to most reports, he sustained a complete spinal cord lesion without
neurological recovery by 8 weeks post injury.
Conclusions:
Surfer's myelopathy, because of its proposed mechanism of injury, is amenable to
medical intervention. Increased awareness of this condition may lead to early
recognition and treatment, which should contribute to improved neurological
outcomes.
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Sagittal T1W and T2W images at 15 hours after the beginning of symptoms
demonstrated mild fusiform expansion of the distal spinal cord and increased T2W
signal (arrows).
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Sagittal T2W MRI on day 2
demonstrated cephalad
progression of increased
T2W signal extending from
the tip of the conus to level
T10 (arrows).
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T1W sagittal image without IV
contrast medium at 4 weeks
demonstrated increased T1W signal
at the distal spinal cord consistent
with hemorrhagic products (arrow).
Annular Tears while Surfing
L3-4
L4-5
L5-1