Surfer's Myelopathy : Case Series and Literature Review

It's in the game: A review of neurological lesions associated with sports

INTRODUCTION

The practice of sports may lead to neurological injuries. While relatively uncommon (overall incidence of approximately 2.5%), and mostly benign and transient, some conditions may be life-threatening and permanent. Thus, both clinical neurologists and sports physicians should be aware of their existence and relevance. We aimed to review all sports-related neurological injuries and illnesses reported in the literature.

METHODS

Following SANRA guidelines, we performed a narrative review and searched PubMed and Scopus databases. Relevant sports were selected based on their recognition as an Olympic sport by the International Olympic Committee. Chronic traumatic encephalopathy (CTE) and other neurodegenerative disorders were not included.

RESULTS

A total of 292 studies were included concerning 33 different sports. The most reported neurological injury was damage to the peripheral nervous system. Traumatic injuries have also been extensively reported, including cerebral haemorrhage and arterial dissections. Non-traumatic life-threatening events are infrequent but may also occur, e.g. posterior reversible encephalopathy syndrome, cerebral venous thrombosis, and arterial dissections. Some conditions were predominantly reported in specific sports, e.g. yips in baseball and golf, raising the possibility of a common pathophysiology. Spinal cord infarction due to fibrocartilaginous embolism was reported in several sports associated with minor trauma.

CONCLUSION

Sports-related neurological injuries are increasingly receiving more social and medical attention and are an important cause of morbidity and mortality. This review may serve as a guide to physicians managing these challenging situations.

Post-kyphoplasty myelopathy, an unusual presentation of post-operative anterior spinal cord infarct: A case report

Highlights

To discuss a rare complication of prone positioning during kyphoplasty.To compare two rare causes of anterior spinal artery infarct secondary to prone positioning: Surfer Myelopathy and post-kyphoplasty myelopathy.

Background

Kyphoplasty is a common, minimally invasive procedure performed to restore vertebral body structure and relieve pain in insufficiency fractures that are refractory to conservative treatments. Complications are infrequent, but typically arise from epidural hematoma, cement embolism, or cement extravasation causing stenosis within the spinal canal or neural foramina. In this case, we discuss a rare complication involving a spinal cord infarct developing several levels above the level of intervention due to compression of the anterior spinal artery.

Case presentation

A 71-year-old female with kyphotic deformity and midthoracic compression fractures underwent a procedurally uneventful T12 kyphoplasty. Pre-procedure MRI demonstrated T12 superior endplate compression deformity with mild retropulsion of the superior endplate. Chronic T6 and T8 compression fractures with kyphotic deformity were also seen. Shortly after the procedure, she developed right leg pain and numbness progressing to profound weakness. She was taken immediately for CT scan of the thoracolumbar spine which was negative for cement extravasation, and subsequent MRI was negative for epidural hematoma. The MRI did show a peculiar finding of spinal cord infarct from T8 to the conus with punctate hemorrhage at T11.

Conclusions

It is postulated that the incomplete cord infarct in this patient occurred due to compression of the anterior spinal artery or radicular arteries during positioning in the setting of kyphotic deformity and posterior osteophyte. The dysmorphic changes seen at T8 may have behaved similarly to a disc herniation in compressing the spinal artery in a prone position.

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.

[A case of surfer's myelopathy with serial imaging examination from early stage after onset]

Surfer's myelopathy is non-traumatic spinal cord injury which develops in beginner surfers. The patient was a 17-year-old female who developed severe paraplegia with bilateral sensory dysfunction below the groin and bladder/rectal dysfunctions after her first surfing lesson. A spinal-cord MRI performed six hours after onset revealed an intramedullary hyperintensity area from T8 to the conus medullaris on the T₂ weighted images. Expansion of this hyperintensity area was observed on Day 3 and showed a reduction on Day 8. After providing intravenous methylpredonisolone, intravenous glycerol and intravenous edaravone, motor function and bladder/rectal functions began to improve after approximately three weeks. In this study, the expansion of the lesion in the early stages of the disease course was observed by sequential spinal MRI. Furthermore, a time lag between improvement according to imaging and improvement in symptoms was also observed.

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.