NonTraumatic Paraplegia in a First Time Surfer

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)
• Absent dorsiflexion
• Minimal plantarflexion
• Intact sensation
• Unequal patellar reflexes
• Absent Achilles and Babinski
• Poor rectal sphincter tone
• L-spine plain films and CT L/S-spine normal

5
Hospital Course

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

6
Initial MRI

• MRI L-spine
• Consistent with cord ischemia

7
MRI at 48 hours

• Transferred to ICU
• Paraplegia to T11

8
Discussion

• Surfing injuries are primarily traumatic in
  nature
• Contact with surfboard
• Collision
• Hydrodynamic forces
• 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
Surfers 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
• All were first time surfers
• Gender 8 male, 1 female
• Age 21-30 years
• All had increased signal on MRI from low thoracic
  vertebra to conus medullaris
• 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
• Avulsion of perforating vessels
• Vasospasm of artery of Adamkiewicz

12
Why Novice Surfers?

• Only 4-5 of time surfing involves wave riding
• 50 spent paddling out
• 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 case validates a potential grim prognosis
• 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
• Prevention through education of risks and proper
  technique

15
Questions?
16
References

• Thompson TP, Pearce J, et al. Surfers
  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 35115-117
• 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
  631113-1120
• Mendez-Villanueva A, Bishop D. Physiological
  Aspects of Surfboard Riding Performance, Sports
  Med. 2005 35(1) 55-70