Surfer's myelopathy: an atypical case presentation

Acute flaccid paralysis of a new surfer: A case report

RATIONALE

Surfer's myelopathy is a rare atraumatic spinal cord injury most frequently experienced by novice surfers. Patients often experience back pain, followed by motor, sensory, bowel, and bladder involvement. Here, we report a case of surfer's myelopathy.

PATIENT CONCERNS

The patient presented with acute low back pain associated with lower limb weakness, sensory loss, urinary retention, and perineal paraesthesia 1 hour after her first surf lesson.

DIAGNOSIS

On arrival at the emergency department, she was noted to have flaccid paralysis with flickers in both lower limbs, reduced sensation in the midthoracic region, reduced anal tone, and saddle anesthesia. Magnetic resonance imaging of the spine revealed evidence of restricted diffusion from T6 to the level of the conus. Extensive investigations, including cerebrospinal fluid analysis, vasculitides/paraneoplastic screening, and further imaging, were unremarkable. She was diagnosed with complete T7 spinal cord injury secondary to surfer's myelopathy.

INTERVENTIONS

She subsequently received methylprednisolone and was transferred to the spinal injury unit for rehabilitation. As she experienced persistent neuropathic pain at the level of the injury, she received input from the local pain team. One month after the injury, the patient developed swelling of the right thigh associated with reduced internal and external rotation of the right hip, impacting rehabilitation. The patient was diagnosed with heterotopic ossification following a triple-phase bone scan. She then received intravenous zolendronic acid, which had a good effect.

OUTCOMES

Four months after the initial presentation, she was discharged to the community. Despite no improvement in her neurological status, she was independent of transfers and mobility with a wheelchair. In addition, she managed her neurogenic bowel and bladder independently with intermittent self-catheterization and a transanal irrigation system. At 6 months, she engaged well with returning to drive program and vocational rehabilitation.

LESSONS

Neurological recovery from surfer's myelopathy has been shown to vary from complete recovery to minimal recovery. With a spinal-specific rehabilitation program, this patient remains independent of her activities of daily living. Surfer's myelopathy often occurs in inexperienced surfers; therefore, it is crucial to provide education to surfers and instructors.

Is Surfer's myelopathy an acute hyperextension-induced myelopathy? A systematic synthesis of case studies and proposed diagnostic criteria

BACKGROUND

Surfer's myelopathy is a rare complication of spinal hyperextension originally described in novice surfers. However, reports from patients practicing different activities had risen.

AIM

To systematically synthesize the epidemiological and clinical evidence on acute hyperextension-induced myelopathy ("Surfer's myelopathy") and propose new diagnostic criteria.

METHODS

We systematically searched four databases for all observational and case studies on the topic. We performed a narrative synthesis to propose diagnostic criteria and tested the criteria retrospectively on the included cases. A case report is also presented.

RESULTS

Forty-two articles reporting 104 cases (median age 19 years, slightly male predominance) were included. All cases reported a nontraumatic hyperextension event (58% after surfing). All of the cases presented pain of hyperacute onset. The most frequent clinical feature was bladder or bowel dysfunction (84%). The thoracic region was the most frequently affected (87%) with longitudinal involvement until the conus (67%). At discharge or follow-up, 52% partially recovered. We propose five diagnostic criteria with three levels of certainty (definite, probable, and possible): (1) nontraumatic spine hyperextension activity (in individuals with no pre-existent spinal disease); (2) hyperacute onset (with acute pain onset); (3) spinal cord injury clinic (motor, sensory, or autonomic deficit); (4) MRI findings with central spinal cord abnormalities (multiple segments); and (5) no other alternative diagnosis. We identified 88% definite and 12% probable/possible cases.

CONCLUSION

The acute hyperextension-induced myelopathy could occur not only during surfing but also during other activities. Therefore, increased awareness and education among sports communities and general physicians are needed.