What is the management and treatment for Surfer's myelopathy?

Surfer's Myelopathy: Management and Treatment

Immediate Recognition and Diagnosis

Surfer's myelopathy is a devastating nontraumatic spinal cord infarction affecting novice surfers, with only a 42% neurological recovery rate, and immediate recognition with aggressive early intervention is critical to prevent permanent paraplegia. 1

Clinical Presentation to Recognize

• Acute onset of back pain rapidly progressing to bilateral lower extremity weakness, paresthesia, and anesthesia within hours of first-time surfing 1, 2
• Bladder and bowel dysfunction developing alongside motor deficits 2, 3
• Complete or incomplete paraplegia at thoracic/conus medullaris level (typically T9-T12) 1, 3
• Symptoms begin during or immediately after prolonged prone positioning with back hyperextension while paddling 4, 3

Diagnostic Imaging

• MRI of the spine with thin axial cuts showing T2-weighted hyperintense signal in the central spinal cord within 24-72 hours of onset 1, 2
• Gadolinium enhancement and diffusion-weighted imaging are not helpful for diagnosis 1
• Spinal angiography is underutilized but valuable, potentially showing absence of radicular arteries or artery of Adamkiewicz, confirming vascular etiology 1, 5
• Rule out longitudinally extensive transverse myelitis (LETM) and other causes of acute myelopathy through clinical history 2

Treatment Algorithm

First-Line Acute Intervention (Within First 24-72 Hours)

Induced hypertension should be initiated immediately to improve spinal cord perfusion, as this approach has shown superior outcomes compared to steroids alone, with one patient achieving almost full recovery 5

• Aggressive hydration combined with induced hypertension to maximize spinal cord blood flow 5
• Early spinal angiography with consideration for intra-arterial intervention if vascular occlusion is identified 5
• High-dose intravenous methylprednisolone (1g daily for 3-5 days) can be administered, though evidence is mixed—patients receiving steroids improved only 55% of the time, and two patients treated with steroids alone remained completely paraplegic 1, 5

Alternative Acute Interventions

• Intravenous tissue plasminogen activator (tPA) may be considered in the hyperacute phase if presentation mimics acute spinal cord infarction 5
• No standardized treatment protocol exists, but early recovery within 24-72 hours is the strongest predictor of long-term neurological outcome 5, 3

Prognostic Factors

Poor Prognosis Indicators

• American Spinal Injury Association (ASIA) class A (complete deficit) at presentation—no improvement has been reported in these cases 1
• Complete paraplegia affecting more than 50% of cases, with devastating permanent outcomes including lifelong catheterization for bladder-bowel dysfunction 1, 5, 3
• Delayed presentation beyond the initial 24-72 hour window significantly reduces recovery potential 5

Favorable Prognosis Indicators

• Incomplete deficits at presentation often improve within 24 hours of onset 1
• Early recovery within the first 24-72 hours strongly predicts long-term neurological improvement 5

Pathophysiology and Risk Factors

The mechanism involves hyperextension of the back combined with Valsalva maneuver during attempts to stand on the surfboard, leading to:

• Dynamic compression of the artery of Adamkiewicz causing vasculature insufficiency 4
• Increased intraspinal pressure from sustained hyperextension in prone position 4, 3
• Repetitive mechanical stress from flexion-extension movements of the spinal column 3
• Anatomical variations in spinal cord vascular supply may predispose certain individuals 2

High-Risk Population

• Novice surfers attempting the sport for the first time, almost uniformly young and healthy with no pre-existing spinal disease 1, 4
• Also reported in yoga, Pilates, gymnastics, and ballet practitioners performing sustained or repeated spinal extension 4

Prevention and Education

Public awareness campaigns targeting surf schools and instructors are essential, as education may be the most effective intervention given the poor prognosis once complete deficit occurs 1

• Warn novice surfers about the risk of prolonged prone hyperextension positioning 4, 3
• Encourage gradual progression in surfing activities rather than extended initial sessions 3
• Instruct immediate cessation of activity and emergency evaluation if back pain develops during surfing 5

Critical Pitfalls to Avoid

• Delaying treatment while awaiting MRI confirmation—initiate induced hypertension and hydration based on clinical suspicion alone 5
• Relying solely on steroids without addressing spinal cord perfusion through induced hypertension 5
• Failing to obtain thorough history of first-time surfing or hyperextension activities, leading to misdiagnosis as transverse myelitis 2
• Underutilizing spinal angiography in the acute phase when intra-arterial intervention might be beneficial 1, 5