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

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

3. 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

4. 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

5. 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

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

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

8. 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)

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

10. Literature Review  Thompson TP, et al. Spine, 2004. 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: 21-30 years Age: 21-30 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

11. 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

12. 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

13. 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

14. 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

15. Questions?

16. References  Thompson TP, Pearce J, et al. Surfer’s MyelopathySpine. 2004; 29(16): E353-356  Thompson TP, Pearce J, et al. Surfer’s Myelopathy, Spine. 2004; 29(16): E353-356  Allen RH, Straehley CJ, et al. Surfing Injuries at Waikiki, JAMA. 1977; 237: 668-670  Hartung GH, Goebert DA, et al. Epidemiology of Ocean Sports-Related Injuries in Hawaii, Hawaii Medical Journal. 1990; 49(2): 52-56  Nathason A, Haynes P, Galanis D. Surfing Injuries, Am J Emerg Med. 2002; 20(3):155-160  Nathason A, Bird S, Dao Lealand, Tam-Sing K. Competitive Surfing Injuries: A Prospective Study of Surfing Related Injuries Among Contest Surfers, Am J of Sports Med. 2007; 35:115-117  Sunshine S. Surfing Injuries, Curr Sports Med Rep. 2003; 2(3): 136-141  Taylor KS, Zoltan TB, Achar SA. Medical Illness and Injuries Encountered During Surfing, Curr Sports Med Rep. 2006; 5(5): 262-267  Taylor DM, Bennett D, et al. Acute Injury and Chronic Disability Resulting from Surfboard Riding, J Sci Med Sport. 2004; 7(4): 429-437  Cheshire WP, Santos CC, et al. Spinal Cord Infarction: Etiology and Outcome, Neurology. 1996; 47(2): 321-330  Novy J, Carruzzo A, et al. Spinal Cord Ischemia: Clinical and Imaging Patterns, Pathogenesis, and Outcomes in 27 Patients, Arch Neurol. 2006; 63:1113-1120  Mendez-Villanueva A, Bishop D. Physiological Aspects of Surfboard Riding Performance, Sports Med. 2005; 35(1): 55-70