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 Surfer’s Myelopathy Nontraumatic Myelopathy Complete Paraplegia Annular Tears

History First reported in 2004 as a series of nine cases Pearce; Spine 2004; Vol 29; No: 16

Atraumatic injury to the cord Affects first-time surfers 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 9 Cases 9 presented with back pain 8 with paraparesis 8 with urinary retention 3 with sensory disturbances 1 with paraplegia

2012 Review 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 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 Average age of 25 New to surfing Initial back pain Relatively rapid progression of neurological symptoms (<24 hours)

Reported Outcomes 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 Hyperextension leading to ischemia? Watershed zones within the cord Concussive forces of the waves? Less likely given the nature of the presentation Thrombotic events? Surfer’s myelopathy is considered to be an ischemic injury of the lower thoracic spinal cord.1–5 The continuous prone hyperextended posture while paddling has been suggested as a main cause of insufficiency of blood flow to the spinal cord, which possibly causes avulsion of perforating vessels, vasospasm of the Adamkiewicz artery, or transient ischemia in areas of borderline perfusion as a result of tension on the spinal cord with hyperextension.1,2 Other possible mechanisms including venous infarction from inferior vena cava obstruction, caused by the liver while lying prone over the surfboard,2 or fibrocartilagenous embolism, which is potentially triggered by the Valsalva maneuver while standing up on the surfboard, are presumed.2–5 However, the pathogenesis of surfer’s myelopathy has been enigmatic.  

Risk Factors Thin body habitus Underdeveloped back musculature Recent long-distance travel Dehydration

Why Thoracic Spine 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. In approximately 70% of cases, the Adamkiewicz artery originates from an intercostal or lumbar artery on the left side of the vertebral column and most frequently between the vertebral levels T8 to L1.7 Then the Adamkiewicz artery courses through the intervertebral foramina along with the nerve root and runs into the anterior spinal artery.8 In the lower thoracic portion (T11–T12, T12–L1), the range of flexion/extension is larger than in the upper and middle portion.10 As in the lumbar spine, extending the spine may cause bulging of intervertebral discs, thickening of the ligamentum flavum,11decrease in the cross-sectional area of the intervertebral foramina,12 and nerve root compromise;13 hence, it can possibly cause mechanical compression of the Adamkiewicz artery. On the other hand, flexion causes the largest canal length change and generates axial tension in the entire cord and nerve roots.14Repetitive stretching of the spinal cord and tensile overload of the nerve root may result in vasospasm or persistent stricture of the Adamkiewicz artery under the strain.

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 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 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. 2

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 Israel Avilés-Hernández, MD,1,2 Inigo García-Zozaya, MD,2 and Jorge M DeVillasante, MD2 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.

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).

Sagittal T2W MRI on day 2 demonstrated cephalad progression of increased T2W signal extending from the tip of the conus to level T10 (arrows).

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