Non-Traumatic Paraplegia in a First Time Surfer CPT Moses H. Cheng CPT Elizabeth A. Durbin Tripler Army Medical Center March 2007

Introduction  Novice surfers with non-traumatic back pain are at increased risk for paraplegia  There are potentially catastrophic outcomes of back pain

The Case  37-year old AD male with acute low back pain after attempting surfing for the first time  Pain became severe with transient sensory complaints  Decreased reflexes and unable to ambulate

Arrival at Tripler (6 hours after initial symptoms)  Lower extremity neuro exam Decreased muscle strength (3/5) Decreased muscle strength (3/5) Absent dorsiflexion Absent dorsiflexion Minimal plantarflexion Minimal plantarflexion Intact sensation Intact sensation Unequal patellar reflexes Unequal patellar reflexes Absent Achilles and Babinski Absent Achilles and Babinski Poor rectal sphincter tone Poor rectal sphincter tone  L-spine plain films and CT L/S-spine normal

Hospital Course Worsened lower extremity deficits Worsened lower extremity deficits Bilateral strength 1/5 Bilateral strength 1/5 Sensory loss L4 to S5 Sensory loss L4 to S5

Initial MRI MRI L-spine Consistent with cord ischemia Consistent with cord ischemia

MRI at 48 hours Transferred to ICU Paraplegia to T11 Paraplegia to T11

Discussion  Surfing injuries are primarily traumatic in nature Contact with surfboard Contact with surfboard Collision Collision Hydrodynamic forces Hydrodynamic forces Impact with the ocean floor Impact with the ocean floor  Incidence of head and neck injuries is 34%-37%  Most craniospinal injuries are secondary to impact with the sand or being hit by a surfboard (JAMA, 1977)

Surfer’s Myelopathy Unique syndrome involving a first time surfer who develops non-traumatic back pain and paraparesis with sensory and urinary symptoms

Literature Review  Thompson TP, et al. Spine, Case series of 9 patients with non-traumatic paraparesis/paraplegia Case series of 9 patients with non-traumatic paraparesis/paraplegia All were first time surfers All were first time surfers Gender: 8 male, 1 female Gender: 8 male, 1 female Age: years Age: years All had increased signal on MRI from low thoracic vertebra to conus medullaris All had increased signal on MRI from low thoracic vertebra to conus medullaris One with residual paraplegia One with residual paraplegia

Postulated Mechanism Prolonged prone hyperextension of back and neck can cause ischemia of spinal cord Infarction of watershed areas of perfusion Infarction of watershed areas of perfusion Avulsion of perforating vessels Avulsion of perforating vessels Vasospasm of artery of Adamkiewicz Vasospasm of artery of Adamkiewicz

Why Novice Surfers?  Only 4-5% of time surfing involves wave riding 50% spent paddling out 50% spent paddling out 40% spent stationary 40% spent stationary  Novice surfers spend extensive time lying prone with neck and back hyperextended

What Our Report Adds  Initial symptoms may be delayed in presentation Our patient developed pain after exiting the water Our patient developed pain after exiting the water  Our case validates a potential grim prognosis Previous series had 1 out of 9 with residual paraplegia Previous series had 1 out of 9 with residual paraplegia

Conclusion  Novice surfers are at risk for spinal cord injury  Body position while surfing is a risk factor for cord injury  Early recognition and consultation Goal to ensure perfusion of cord Goal to ensure perfusion of cord  Prevention through education of risks and proper technique

Questions?

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