Surfer's myelopathy without surfing: a report of two pediatric patients

Guidelines for management of pediatric acute hyperextension spinal cord injury

Pediatric acute hyperextension spinal cord injury (SCI) named as PAHSCI by us, is a special type of thoracolumbar SCI without radiographic abnormality and highly related to back-bend in dance training, which has been increasingly reported. At present, it has become the leading cause of SCI in children, and brings a heavy social and economic burden. Both domestic and foreign academic institutions and dance education organizations lack a correct understanding of PAHSCI and relevant standards, specifications or guidelines. In order to provide standardized guidance, the expert team formulated this guideline based on the principles of science and practicability, starting from the diagnosis, differential diagnosis, etiology, admission evaluation, treatment, complications and prevention. This guideline puts forward 23 recommendations for 14 related issues.

Acute hyperextension myelopathy in children: Radiographic predictors of clinical improvement

STUDY DESIGN

Retrospective case series SETTING: Three hospitals in China.

OBJECTIVE

Previous research indicates that only neurological status on admission determines prognosis of acute hyperextension myelopathy (AHM). The object of this study is to analyze other unfavorable predictors of AHM in children.

METHODS

The clinical data of children with AHM were retrospectively analyzed. The ASIA impairment scale (AIS) grade was recorded upon admission and at last follow-up. Intramedullary lesion length (IMLL) was measured in the sagittal T2-weighted imaging (T2WI) within two weeks after onset; gadolinium enhancement in the cord was recorded for each patient. Relationships among AIS grade, IMLL, gadolinium enhancement in the cord, and clinical improvement were assessed.

RESULTS

A total of 33 patients were included in this retrospective study. IMLL between complete and incomplete injury was significantly different (p < 0.01) in the subacute stage, and no difference was observed in the acute stage. Correlation analysis revealed that AIS grade on admission (r = 0.906, p < 0.001) was significantly positively correlated with clinical improvement. IMLL (r = -0.608, p < 0.001) and abnormal gadolinium enhancement (r = -0.816, p < 0.001) in the cord in the subacute stage were significantly negatively correlated with clinical improvement. There were no associations between IMLL in the acute stage and clinical improvement (r = -0.248, p = 0.242). The statistically significant predictors of clinical improvement were AIS grade on admission, IMLL in the subacute stage, and abnormal gadolinium enhancement.

CONCLUSION

IMLL in the subacute stage and abnormal gadolinium enhancement in the cord are two other prognostic predictors of AHM in children.

Magnetic resonance imaging evaluation of spinal cord lesions: what can we find? - Part 1. Neoplastic, vascular, metabolic, and traumatic injuries

Diseases involving the spinal cord include a heterogeneous group of abnormalities, including those of inflammatory, infectious, neoplastic, vascular, metabolic, and traumatic origin. Making the clinical differentiation between different entities is often difficult, magnetic resonance imaging being the diagnostic method of choice. Although the neuroimaging findings are not pathognomonic, many are quite suggestive, and the radiologist can assist in the diagnosis and, consequently, in the therapeutic guidance. In this first part of our article, the objective is to review the magnetic resonance imaging findings of the main neoplastic, vascular, metabolic, and traumatic spinal cord injuries.

Evaluation and Management of Acute Myelopathy

Acute myelopathies are spinal cord disorders characterized by a rapidly progressive course reaching nadir within hours to a few weeks that may result in severe disability. The multitude of underlying etiologies, complexities in confirming the diagnosis, and often unforgiving nature of spinal cord damage have always represented a challenge. Moreover, certain slowly progressive myelopathies may present acutely or show abrupt worsening in specific settings and thus further complicate the diagnostic workup. Awareness of the clinical and magnetic resonance imaging characteristics of different myelopathies and the specific settings where they occur is fundamental for a correct diagnosis. Neuroimaging helps distinguish compressive etiologies that may require urgent surgery from intrinsic etiologies that generally require medical treatment. Differentiation between various myelopathies is essential to establish timely and appropriate treatment and avoid harm from unnecessary procedures. This article reviews the contemporary spectrum of acute myelopathy etiologies and provides guidance for diagnosis and management.

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.

Surfer Myelopathy in Children: A Case Series Study

OBJECTIVE

The cause of surfer myelopathy remains enigmatic and long-term follow-up outcomes are not well documented. In the present study, the mechanisms underlying surfer myelopathy in children are analyzed and the long-term follow-up outcomes are reported.

METHODS

Clinical data from 3 institutions were retrospectively analyzed. Patients were assessed using the American Spinal Injury Association Impairment Scale (AIS) on admission and at follow-up. The mechanisms were studied by analyzing patients' medical history, magnetic resonance imaging, and magnetic resonance angiography. The prognosis of long-term follow-up was summarized.

RESULTS

Thirty-one children were diagnosed with surfer myelopathy. Intramedullary high-intensity T2 signal from mid to lower thoracic level to conus was found during the acute stage. Follow-up magnetic resonance imaging in the subacute stage showed cranial progression of the T2 hyperintensity up to 1-10 vertebral segments, and no neurologic deterioration was found. Intramedullary lesion length between the complete and incomplete injury was significantly different (P < 0.01) in the subacute phase. Flow voids around nerve roots and in the epidural space were detected in 18 patients and 15 patients, respectively, on axial T2-weighted imaging. Enlarged tortuous veins were found in 3 of 6 patients who underwent spinal magnetic resonance angiography, which were discontinuous around nerve root. During long-term follow-up, no patients with AIS grade A recovered, and atrophic cord was observed in the later stage in 14 patients. Patients with incomplete injury had different recoveries.

CONCLUSIONS

Surfer myelopathy in children is caused by spinal venous hypertension. The AIS grade on admission is a predictor of prognosis.

Surfer's myelopathy: A review of etiology, pathogenesis, evaluation, and management

Context: Surfer's myelopathy (SM) is an acute syndrome identified by nontraumatic paraparesis or paraplegia. Though traditionally tied to first-time surfers, the condition encompasses any activity involving hyperextension of the back such as gymnastics, yoga, and Pilates.Methods: MEDLINE^® and Google Scholar literature searches were gathered to identify relevant case reports for determining the etiology, pathogenesis, evaluation, and management of SM.Results: While the rare nature of SM limits its full understanding, studies have pinpointed that hyperextension in the back leads to vasculature insufficiency secondary to dynamic compression of the artery of Adamkiewicz. In surfing, this hyperextension combined with the execution of the Valsalva maneuver while trying to stand up on the surfboard likely increases intraspinal pressure. Due to its nontraumatic origin, the presence of SM is not immediately clear. Moreover, its similarity in clinical and radiological presentations with other entities can further complicate diagnosis. Seemingly, idiopathic urological symptoms can be explained by the physician if they conduct a thorough history.Conclusion: In an effort to raise awareness for the practicing physician, we presently review the etiology, diagnosis, treatment, and prolonged effects of SM. With the surging popularity of surfing as well as the advent of children participating in precarious sports and activities at an earlier age, we can expect a rising incidence of traumatic and nontraumatic spinal cord injuries. Neurologists, urologists, emergency medicine and sports medicine physicians alike can utilize this review to build a high index of suspicion for SM. The risk factors for SM should be conveyed to those participating in novices in surfing, yoga, gymnastics, ballet, and any activity enabling sustained or repeated spinal extension. Increased general awareness will facilitate increased symptom recognition in order to arrest aggravation of injury.

Spinal cord infarction in children: Can gymnastics be a cause?

INTRODUCTION

Spinal cord infarction (SCI) in children is rare and difficult to diagnose. Fibrocartilaginous embolism (FCE) is probably the underlying cause for some unexplained cases of spinal cord infarcts. Abrupt back pain followed by a progressive syndrome of myelopathy appears to be the typical presentation, with a close temporal relationship between the onset of symptoms and preceding minor trauma. Supportive care and rehabilitation are essential in the treatment of children with SCI.

CASE REPORT

A previously healthy 12-year-old girl who practiced acrobatic gymnastics was admitted to a rehabilitation centre 14 days after being diagnosed with an acute anterior SCI with no identified cause. Sensory modality of pin prick and light touch were impaired, with the former more significantly affected. She was not able to run and had difficulty on monopodal standing and performing motor sequencing. Additionally, she mentioned ineffective cough along with flatus incontinence and normal bladder function. After a 4-week multidisciplinary rehabilitation program her neurologic deficits improved.

DISCUSSION

Given the patient's age and clinical presentation, a literature review led to the consideration of FCE as the most likely definitive diagnosis. It should be recognized as a cause of SCI especially in those involved in sport activities, even if previous trauma is denied.

Surfer's myelopathy: an atypical case presentation

INTRODUCTION

Surfer's myelopathy (SM) is a rare nontraumatic spinal cord injury seen in beginner surfers and people participating in activities involving prolonged lumbar hyperextension. The majority of cases of SM have been reported in younger patients under 40 years of age, with initial magnetic resonance imaging (MRI) showing T2 signal abnormalities. We present a case of SM in a person over 40 years old whose initial MRI did not show the T2 signal abnormalities usually reported in SM.

CASE PRESENTATION

A 43-year-old male in good physical condition went surfing for the first time and developed generalized back pain that progressed to include bilateral lower extremity pain with numbness and weakness. MRI within 11-12 h of symptom onset revealed no acute T2 signal abnormalities. At the time of initial presentation he had classification consistent with a T12 American Spinal Injury Association Impairment Scale (AIS) A and at rehabilitation discharge, 6 weeks later, he had classification of T12 AIS B.

DISCUSSION

Not all cases of SM present similarly. As surfing is a popular sport, education on early identification of warning signs is crucial for instructors and trainees, as well as health care providers. Our case highlights the importance of a comprehensive history and physical examination in developing the diagnosis, especially in presentations that are not classic in nature.

Paraplesia after surfing in a young female novice surfer: a case report on surfer's myelopathy

Background

Surfer's myelopathy is a non‐traumatic spinal cord injury that was first described in a publication in 2004. However, most emergency physicians are not familiar with this rare disease.

Case Presentation

The patient was a 19‐year‐old female novice surfer. She had experienced back discomfort without trauma during her surfing lessons. The discomfort turned to dysesthesia of both legs. She could not walk after 1 h and was brought to our hospital. Physical examination revealed weakness and dysesthesia of both legs, absent deep tendon reflexes, bilaterally positive Babinski reflex, and bladder and rectal disturbance. Spine magnetic resonance imaging revealed T2 prolongation from T7 to the medullary cone. She was diagnosed with surfer's myelopathy and treated conservatively. She recovered well and was discharged on day 28.

Conclusion

Emergency physicians must be better informed about surfer's myelopathy. Novice surfers and instructors should be educated on the early signs and symptoms of this condition.

Traumatic spinal cord injury due to human tower accident in catolonia

Study design

Retrospective case series.

Objectives

The aim of this paper was to review the cases of SCI associated with human towers in the neurorehabilitation hospital Guttmann in Barcelona, clarify the mechanisms of these accidents and classify the injuries.

Settings and methods

Data and history were retrospectively reviewed to detect SCI patients injured from human tower accidents admitted at the Guttmann Institute, Barcelona, in the period 1965-2017, from patient histories and interviews with patients and their relatives.

Results

In total, five men with SCI acquired from "human tower" accidents were admitted between 1988 and 2017. All of them were at the base of the tower. They were all injured at cervical level, with very severe injury (AIS-A in two, AIS-B in one, and AIS-C in two). Two died due to pneumonia associated to mechanical ventilation at 4 and 10 years post injury.

Conclusion

Human tower is a rare cause of traumatic tetraplegia in Catalonia. People forming the base of the tower are at greater risk for injury. Moreover, in our case series, all accidents causing SCI occurred when the human tower was greater than seven levels and had over three participants at each level.

Non-traumatic myelopathy associated with prolonged hyperextension during swimming: an unusual variation of Surfer's Myelopathy

Introduction

Surfer's myelopathy (SM) is a rare cause on non-traumatic acute myelopathy. This has classically been described in novice surfers however has been reported in other scenarios.

Case presentation

We present a case of non-traumatic paraparesis associated with prolonged cervical hyperextension during swimming with imaging characteristics consistent with an unusual variation of SM in a swimmer.

Discussion

SM and its variants should be considered in the differential diagnosis of any patient presenting with an anterior spinal cord syndrome with a history of either sustained or repeated spinal hyperextension.

Spinal cord injury with central cord syndrome from surfing

Introduction

Central cord syndrome (CCS) is an injury to the center of the spinal cord. It is well known as a hyperextension injury, but it has never been described as a surfing injury. Our report describes this injury in detail.

Case presentation

A 35-year-old male novice surfer presented to the emergency department with acute tetraplegia following falling off his surfboard and hitting sea floor at a shallow beach break. He was rescued by a fellow surfer while floating in the sea and unable to raise his head above sea level. Upon arrival at the hospital, tetraplegia and sensory deficits were noted. Radiological investigations showed advanced spinal stenosis at C4-6 levels. T2 magnetic resonance imaging (MRI) demonstrated myelopathy at C5-C6 level. He was diagnosed as having central cord syndrome, treated conservatively, and regained near full neurologic recovery after a month of rehabilitation.

Discussion

Unique sport activities lead to unique injuries. It is important to accurately describe these injuries in order to create protective measures against them. Neurologic injuries in surfers are uncommon. With low-energy trauma, surfer's myelopathy is still the most common diagnosis, but central cord syndrome should be in the differential diagnosis.