Wacky Sports InjuriesSpine Injuries in Surfers

Jaspal R Singh MDAssistant Professor of Rehabilitation Medicine

Director of Interventional Spine

Disclosures

Jaspal R Singh MDbull Consultant- Physicianrsquos Pharmaceutical Solutionsbull Consultant- Kimberly Clark

Cases

1 Surferrsquos Myelopathy

2 Nontraumatic Myelopathy

3 Complete Paraplegia

4 Annular Tears

History

bull First reported in 2004 as a series of nine cases

bull Pearce Spine 2004 Vol 29 No 16

Surfers Myelopathy

bull Atraumatic injury to the cordbull Affects first-time surfers

ndash Hyperextension moment in a ldquopredisposedrdquo individual

bull MRI shows signal change in the affected portions of the cord

Thompson et al in 2004

bull 9 Casesndash 9 presented with back painndash 8 with paraparesisndash 8 with urinary retentionndash 3 with sensory disturbancesndash 1 with paraplegia

2012 Review

bull 19 casesbull 15-46 yobull Novice surfersbull All had lower back discomfortbull 10-60 minute onset of weakness and paresthesiasbull Within minutes of onset unable to walk

MRI Findings

bull All had hyperintense T2 signal from mid- to lower thoracic level to the conusbull No segmental imagebull Restricted diffusion in 610 patientsbull No evidence of aortic injurybull Proposed mechanism is Artery of Adamkiewicz vasospasm

Clinical Presentation

bull Average age of 25bull New to surfingbull Initial back painbull Relatively rapid progression of neurological symptoms (lt24 hours)

Reported Outcomes

bull At time of discharge 9 casesndash 3 patients had complete recovery ndash 4 patients had ldquomildrdquo weakness but no sensory deficitsndash 3 had urinary retentionndash 1 patient remained paraplegic

Proposed Mechanisms

bull Hyperextension leading to ischemiandash Watershed zones within the cord

bull Concussive forces of the wavesndash Less likely given the nature of the presentation

bull Thrombotic events

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

Disclosures

Jaspal R Singh MDbull Consultant- Physicianrsquos Pharmaceutical Solutionsbull Consultant- Kimberly Clark

Cases

1 Surferrsquos Myelopathy

2 Nontraumatic Myelopathy

3 Complete Paraplegia

4 Annular Tears

History

bull First reported in 2004 as a series of nine cases

bull Pearce Spine 2004 Vol 29 No 16

Surfers Myelopathy

bull Atraumatic injury to the cordbull Affects first-time surfers

ndash Hyperextension moment in a ldquopredisposedrdquo individual

bull MRI shows signal change in the affected portions of the cord

Thompson et al in 2004

bull 9 Casesndash 9 presented with back painndash 8 with paraparesisndash 8 with urinary retentionndash 3 with sensory disturbancesndash 1 with paraplegia

2012 Review

bull 19 casesbull 15-46 yobull Novice surfersbull All had lower back discomfortbull 10-60 minute onset of weakness and paresthesiasbull Within minutes of onset unable to walk

MRI Findings

bull All had hyperintense T2 signal from mid- to lower thoracic level to the conusbull No segmental imagebull Restricted diffusion in 610 patientsbull No evidence of aortic injurybull Proposed mechanism is Artery of Adamkiewicz vasospasm

Clinical Presentation

bull Average age of 25bull New to surfingbull Initial back painbull Relatively rapid progression of neurological symptoms (lt24 hours)

Reported Outcomes

bull At time of discharge 9 casesndash 3 patients had complete recovery ndash 4 patients had ldquomildrdquo weakness but no sensory deficitsndash 3 had urinary retentionndash 1 patient remained paraplegic

Proposed Mechanisms

bull Hyperextension leading to ischemiandash Watershed zones within the cord

bull Concussive forces of the wavesndash Less likely given the nature of the presentation

bull Thrombotic events

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

Cases

1 Surferrsquos Myelopathy

2 Nontraumatic Myelopathy

3 Complete Paraplegia

4 Annular Tears

History

bull First reported in 2004 as a series of nine cases

bull Pearce Spine 2004 Vol 29 No 16

Surfers Myelopathy

bull Atraumatic injury to the cordbull Affects first-time surfers

ndash Hyperextension moment in a ldquopredisposedrdquo individual

bull MRI shows signal change in the affected portions of the cord

Thompson et al in 2004

bull 9 Casesndash 9 presented with back painndash 8 with paraparesisndash 8 with urinary retentionndash 3 with sensory disturbancesndash 1 with paraplegia

2012 Review

bull 19 casesbull 15-46 yobull Novice surfersbull All had lower back discomfortbull 10-60 minute onset of weakness and paresthesiasbull Within minutes of onset unable to walk

MRI Findings

bull All had hyperintense T2 signal from mid- to lower thoracic level to the conusbull No segmental imagebull Restricted diffusion in 610 patientsbull No evidence of aortic injurybull Proposed mechanism is Artery of Adamkiewicz vasospasm

Clinical Presentation

bull Average age of 25bull New to surfingbull Initial back painbull Relatively rapid progression of neurological symptoms (lt24 hours)

Reported Outcomes

bull At time of discharge 9 casesndash 3 patients had complete recovery ndash 4 patients had ldquomildrdquo weakness but no sensory deficitsndash 3 had urinary retentionndash 1 patient remained paraplegic

Proposed Mechanisms

bull Hyperextension leading to ischemiandash Watershed zones within the cord

bull Concussive forces of the wavesndash Less likely given the nature of the presentation

bull Thrombotic events

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

History

bull First reported in 2004 as a series of nine cases

bull Pearce Spine 2004 Vol 29 No 16

Surfers Myelopathy

bull Atraumatic injury to the cordbull Affects first-time surfers

ndash Hyperextension moment in a ldquopredisposedrdquo individual

bull MRI shows signal change in the affected portions of the cord

Thompson et al in 2004

bull 9 Casesndash 9 presented with back painndash 8 with paraparesisndash 8 with urinary retentionndash 3 with sensory disturbancesndash 1 with paraplegia

2012 Review

bull 19 casesbull 15-46 yobull Novice surfersbull All had lower back discomfortbull 10-60 minute onset of weakness and paresthesiasbull Within minutes of onset unable to walk

MRI Findings

bull All had hyperintense T2 signal from mid- to lower thoracic level to the conusbull No segmental imagebull Restricted diffusion in 610 patientsbull No evidence of aortic injurybull Proposed mechanism is Artery of Adamkiewicz vasospasm

Clinical Presentation

bull Average age of 25bull New to surfingbull Initial back painbull Relatively rapid progression of neurological symptoms (lt24 hours)

Reported Outcomes

bull At time of discharge 9 casesndash 3 patients had complete recovery ndash 4 patients had ldquomildrdquo weakness but no sensory deficitsndash 3 had urinary retentionndash 1 patient remained paraplegic

Proposed Mechanisms

bull Hyperextension leading to ischemiandash Watershed zones within the cord

bull Concussive forces of the wavesndash Less likely given the nature of the presentation

bull Thrombotic events

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

Surfers Myelopathy

bull Atraumatic injury to the cordbull Affects first-time surfers

ndash Hyperextension moment in a ldquopredisposedrdquo individual

bull MRI shows signal change in the affected portions of the cord

Thompson et al in 2004

bull 9 Casesndash 9 presented with back painndash 8 with paraparesisndash 8 with urinary retentionndash 3 with sensory disturbancesndash 1 with paraplegia

2012 Review

bull 19 casesbull 15-46 yobull Novice surfersbull All had lower back discomfortbull 10-60 minute onset of weakness and paresthesiasbull Within minutes of onset unable to walk

MRI Findings

bull All had hyperintense T2 signal from mid- to lower thoracic level to the conusbull No segmental imagebull Restricted diffusion in 610 patientsbull No evidence of aortic injurybull Proposed mechanism is Artery of Adamkiewicz vasospasm

Clinical Presentation

bull Average age of 25bull New to surfingbull Initial back painbull Relatively rapid progression of neurological symptoms (lt24 hours)

Reported Outcomes

bull At time of discharge 9 casesndash 3 patients had complete recovery ndash 4 patients had ldquomildrdquo weakness but no sensory deficitsndash 3 had urinary retentionndash 1 patient remained paraplegic

Proposed Mechanisms

bull Hyperextension leading to ischemiandash Watershed zones within the cord

bull Concussive forces of the wavesndash Less likely given the nature of the presentation

bull Thrombotic events

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

Thompson et al in 2004

bull 9 Casesndash 9 presented with back painndash 8 with paraparesisndash 8 with urinary retentionndash 3 with sensory disturbancesndash 1 with paraplegia

2012 Review

bull 19 casesbull 15-46 yobull Novice surfersbull All had lower back discomfortbull 10-60 minute onset of weakness and paresthesiasbull Within minutes of onset unable to walk

MRI Findings

bull All had hyperintense T2 signal from mid- to lower thoracic level to the conusbull No segmental imagebull Restricted diffusion in 610 patientsbull No evidence of aortic injurybull Proposed mechanism is Artery of Adamkiewicz vasospasm

Clinical Presentation

bull Average age of 25bull New to surfingbull Initial back painbull Relatively rapid progression of neurological symptoms (lt24 hours)

Reported Outcomes

bull At time of discharge 9 casesndash 3 patients had complete recovery ndash 4 patients had ldquomildrdquo weakness but no sensory deficitsndash 3 had urinary retentionndash 1 patient remained paraplegic

Proposed Mechanisms

bull Hyperextension leading to ischemiandash Watershed zones within the cord

bull Concussive forces of the wavesndash Less likely given the nature of the presentation

bull Thrombotic events

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

2012 Review

bull 19 casesbull 15-46 yobull Novice surfersbull All had lower back discomfortbull 10-60 minute onset of weakness and paresthesiasbull Within minutes of onset unable to walk

MRI Findings

bull All had hyperintense T2 signal from mid- to lower thoracic level to the conusbull No segmental imagebull Restricted diffusion in 610 patientsbull No evidence of aortic injurybull Proposed mechanism is Artery of Adamkiewicz vasospasm

Clinical Presentation

bull Average age of 25bull New to surfingbull Initial back painbull Relatively rapid progression of neurological symptoms (lt24 hours)

Reported Outcomes

bull At time of discharge 9 casesndash 3 patients had complete recovery ndash 4 patients had ldquomildrdquo weakness but no sensory deficitsndash 3 had urinary retentionndash 1 patient remained paraplegic

Proposed Mechanisms

bull Hyperextension leading to ischemiandash Watershed zones within the cord

bull Concussive forces of the wavesndash Less likely given the nature of the presentation

bull Thrombotic events

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

MRI Findings

bull All had hyperintense T2 signal from mid- to lower thoracic level to the conusbull No segmental imagebull Restricted diffusion in 610 patientsbull No evidence of aortic injurybull Proposed mechanism is Artery of Adamkiewicz vasospasm

Clinical Presentation

bull Average age of 25bull New to surfingbull Initial back painbull Relatively rapid progression of neurological symptoms (lt24 hours)

Reported Outcomes

bull At time of discharge 9 casesndash 3 patients had complete recovery ndash 4 patients had ldquomildrdquo weakness but no sensory deficitsndash 3 had urinary retentionndash 1 patient remained paraplegic

Proposed Mechanisms

bull Hyperextension leading to ischemiandash Watershed zones within the cord

bull Concussive forces of the wavesndash Less likely given the nature of the presentation

bull Thrombotic events

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

Clinical Presentation

bull Average age of 25bull New to surfingbull Initial back painbull Relatively rapid progression of neurological symptoms (lt24 hours)

Reported Outcomes

bull At time of discharge 9 casesndash 3 patients had complete recovery ndash 4 patients had ldquomildrdquo weakness but no sensory deficitsndash 3 had urinary retentionndash 1 patient remained paraplegic

Proposed Mechanisms

bull Hyperextension leading to ischemiandash Watershed zones within the cord

bull Concussive forces of the wavesndash Less likely given the nature of the presentation

bull Thrombotic events

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

Reported Outcomes

bull At time of discharge 9 casesndash 3 patients had complete recovery ndash 4 patients had ldquomildrdquo weakness but no sensory deficitsndash 3 had urinary retentionndash 1 patient remained paraplegic

Proposed Mechanisms

bull Hyperextension leading to ischemiandash Watershed zones within the cord

bull Concussive forces of the wavesndash Less likely given the nature of the presentation

bull Thrombotic events

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

Proposed Mechanisms

bull Hyperextension leading to ischemiandash Watershed zones within the cord

bull Concussive forces of the wavesndash Less likely given the nature of the presentation

bull Thrombotic events

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

Risk Factors

bull Thin body habitusbull Underdeveloped back musculaturebull Recent long-distance travelbull Dehydration

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

Why Thoracic Spine

bull three regions of anterior vascular supplyndash (1) cervicodorsal regionndash (2) intermediate region (midthoracic area) from T4 to T7 or T8ndash (3) inferior dorsolumbar region

bull midthoracic area is poorly vascularized bull the lower thoracic to the lumbar area is mainly supplied by a single Adamkiewicz

artery bull Among surfers the technique of standing up on a surfboard is called ldquopopping uprdquo

ndash first pushing up onersquos torso by extending both arms from a prone ldquopaddlingrdquo position

ndash second crouching on the surfboard and sliding the legs under the torsondash third standing to a half-rising position which is called the ldquoridingrdquo position ndash Insert VIDEO and PICSndash 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

bull thin and underdeveloped back musculature is a possible risk factor for surferrsquos myelopathy

bull poor stability of the spine may result in accidental overextension or overflexion

bull recommend that novice surfers take mandatory rest periods during surfing lessons ndash (eg 10 mins of rest every 45 mins)ndash the time of lessons should be limited (eg maximum of 90 mins) ndash instructors be educated as to the early detection of studentsrsquo back pain

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

Conclusion

bull Surfing is a popular sport worldwidebull The etiology of surferrsquos myelopathy remains enigmaticbull resulting disability can be devastating bull early detection and early treatment are necessary for the prevention of neurologic

deterioration bull Awareness among clinicians and surfers is desirable bull Immediate imaging (eg MRI with diffusion-weighted images magnetic resonance

angiography and computed tomographic angiography) is desirable for the further elucidation of its pathogenesis

bull Aggressive hydration induced hypertension and empiric corticosteroids are recommended as acute treatments for spinal cord ischemia

bull In addition adequate rehabilitation for the neurologic deficits is indispensable

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

Complete Paraplegia

bull Three patients with diagnoses of surferrsquos myelopathybull (24ndash31 yrs old two men one woman) bull novice surfers bull rapid progression of paraplegia after back pain while taking surfing lessonsbull Despite months of rehabilitation

ndash in all three patients complete paraplegia (T9ndashT12) and bladder-bowel dysfunction remained

bull neurologic outcome of surferrsquos myelopathy is potentially catastrophic

Complete Paraplegia Resulting from Surfers Myelopathy Takakura Tomokazu Yokoyama Osamu Sakuma Fujiko Itoh Ryousuke Romero Ray American Journal of Physical Medicine amp Rehabilitation 92(9)833-837 September 2013

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp Wilkins Inc 2

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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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)

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

copy 2013 by Lippincott Williams amp Wilkins Published by Lippincott Williams amp 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

J Spinal Cord Med 2007 30(3) 288ndash293PMCID PMC2031959 Nontraumatic Myelopathy Associated With SurfingIsrael Avileacutes-Hernaacutendez MD12 Inigo Garciacutea-Zozaya MD2 and Jorge M DeVillasante MD2

bull Resultsbull 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

bull Conclusionsbull Surfers 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

bull 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)

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

bull 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

• Wacky Sports Injuries Spine Injuries in Surfers
• Slide 2
• Disclosures
• Cases
• History
• Surfers Myelopathy
• Thompson et al in 2004
• 2012 Review
• MRI Findings
• Clinical Presentation
• Reported Outcomes
• Proposed Mechanisms
• Risk Factors
• Why Thoracic Spine
• Slide 15
• Slide 16
• Conclusion
• Complete Paraplegia
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• J Spinal Cord Med 2007 30(3) 288ndash293 PMCID PMC2031959 Nont
• Slide 24
• Slide 25
• Slide 26
• Annular Tears while Surfing
• L3-4
• L4-5
• L5-1

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

bull 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

• Wacky Sports Injuries Spine Injuries in Surfers
• Slide 2
• Disclosures
• Cases
• History
• Surfers Myelopathy
• Thompson et al in 2004
• 2012 Review
• MRI Findings
• Clinical Presentation
• Reported Outcomes
• Proposed Mechanisms
• Risk Factors
• Why Thoracic Spine
• Slide 15
• Slide 16
• Conclusion
• Complete Paraplegia
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• J Spinal Cord Med 2007 30(3) 288ndash293 PMCID PMC2031959 Nont
• Slide 24
• Slide 25
• Slide 26
• Annular Tears while Surfing
• L3-4
• L4-5
• L5-1

bull 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

• Wacky Sports Injuries Spine Injuries in Surfers
• Slide 2
• Disclosures
• Cases
• History
• Surfers Myelopathy
• Thompson et al in 2004
• 2012 Review
• MRI Findings
• Clinical Presentation
• Reported Outcomes
• Proposed Mechanisms
• Risk Factors
• Why Thoracic Spine
• Slide 15
• Slide 16
• Conclusion
• Complete Paraplegia
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• J Spinal Cord Med 2007 30(3) 288ndash293 PMCID PMC2031959 Nont
• Slide 24
• Slide 25
• Slide 26
• Annular Tears while Surfing
• L3-4
• L4-5
• L5-1

Annular Tears while Surfing

L3-4

L4-5

L5-1

• Wacky Sports Injuries Spine Injuries in Surfers
• Slide 2
• Disclosures
• Cases
• History
• Surfers Myelopathy
• Thompson et al in 2004
• 2012 Review
• MRI Findings
• Clinical Presentation
• Reported Outcomes
• Proposed Mechanisms
• Risk Factors
• Why Thoracic Spine
• Slide 15
• Slide 16
• Conclusion
• Complete Paraplegia
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• J Spinal Cord Med 2007 30(3) 288ndash293 PMCID PMC2031959 Nont
• Slide 24
• Slide 25
• Slide 26
• Annular Tears while Surfing
• L3-4
• L4-5
• L5-1

L3-4

L4-5

L5-1

• Wacky Sports Injuries Spine Injuries in Surfers
• Slide 2
• Disclosures
• Cases
• History
• Surfers Myelopathy
• Thompson et al in 2004
• 2012 Review
• MRI Findings
• Clinical Presentation
• Reported Outcomes
• Proposed Mechanisms
• Risk Factors
• Why Thoracic Spine
• Slide 15
• Slide 16
• Conclusion
• Complete Paraplegia
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• J Spinal Cord Med 2007 30(3) 288ndash293 PMCID PMC2031959 Nont
• Slide 24
• Slide 25
• Slide 26
• Annular Tears while Surfing
• L3-4
• L4-5
• L5-1

L4-5

L5-1

• Wacky Sports Injuries Spine Injuries in Surfers
• Slide 2
• Disclosures
• Cases
• History
• Surfers Myelopathy
• Thompson et al in 2004
• 2012 Review
• MRI Findings
• Clinical Presentation
• Reported Outcomes
• Proposed Mechanisms
• Risk Factors
• Why Thoracic Spine
• Slide 15
• Slide 16
• Conclusion
• Complete Paraplegia
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• J Spinal Cord Med 2007 30(3) 288ndash293 PMCID PMC2031959 Nont
• Slide 24
• Slide 25
• Slide 26
• Annular Tears while Surfing
• L3-4
• L4-5
• L5-1

L5-1

• Wacky Sports Injuries Spine Injuries in Surfers
• Slide 2
• Disclosures
• Cases
• History
• Surfers Myelopathy
• Thompson et al in 2004
• 2012 Review
• MRI Findings
• Clinical Presentation
• Reported Outcomes
• Proposed Mechanisms
• Risk Factors
• Why Thoracic Spine
• Slide 15
• Slide 16
• Conclusion
• Complete Paraplegia
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• J Spinal Cord Med 2007 30(3) 288ndash293 PMCID PMC2031959 Nont
• Slide 24
• Slide 25
• Slide 26
• Annular Tears while Surfing
• L3-4
• L4-5
• L5-1