Rapid Paralysis in Surfers
Dr Chang, the medical director of the Neuroscience Institute/Neurocritical Care, director, Stroke Center, The Queen’s Medical Center, and associate clinical professor of medicine and surgery, University of Hawaii, Honolulu, began her research in the 1990s. She had seen a number of surfers presenting with acute symptoms, such as urinary retention and progressive paraparesis, appearing to stem from spinal cord injuries. Dr Chang said of the novice surfers, “As they emerged from the water and gradually took on more gravity, they noticed that their legs were weakening; by the time they reached their towel on the beach, they couldn’t walk.” Amassing date over a number of years, Dr Chang noticed that these patients, whilst experiencing similar symptoms, did not have herniated discs, inflammation or spinal fracture as a cause of the condition.
Beginner Surfers and SCI
Publishing a small case series in the journal Neurology in November, Dr Chang outlined her hypothesis that these patients, whose ages ranged from fifteen to forty-six, had an increased risk of ischaemia in the inferior spinal cord due to some anatomic abnormality. One particular habit that many novice surfers engage in could be putting them at risk of this type of injury. Whilst more experienced surfers often sit on their board and wait for waves (see the video below), beginner surfers lay on their front with their spines hyperextended. Dr Chang recommends that surfers avoid lying on their board for long periods of time in this position as it may raise the risk of spinal cord injury from ischaemia.
Complete Paraplegia in Surfers
The study looked at nineteen novice surfers, fourteen of whom were men, who came into the hospital between 2002 and 2011. Five had complete paraplegia and sensory loss and eight had near complete paraplegia. None of these surfers had experienced acute injury or had a pre-existing neurologic injury or symptoms. Eighteen of these surfers had been lying on their board for long periods of time in the hyperextended position before feeling a pop or crack in their back and then experiencing an ache in the lower spine. Weakness and paralysis occurred within minutes of exiting the water as pressure was put on the spine and the effects of the ischemia took hold.
Causes of Spinal Cord Injury in Young Surfers
These patients were tested to rule of cardiogenic or aortic embolism; blood clots forming in the heart or major artery that broke free and traveled through the blood before blocking circulation and causing ischemic spinal cord injury. The surfers had no evidence of ongoing blood vessel blockages or haemorrhaging and their relatively young ages made arteriosclerotic disease unlikely. Instead, the most probable explanation was an acute dynamic compression of a blood vessel or a thrombotic infarction of the main artery feeding the spinal cord, the great anterior radicular artery of Adamkiewicz.
Safer Surfing Habits to Reduce SCI Risk
No patient with this type of condition has died and so Dr Chang has not been able to investigate the full pathology of the phenomenon. The current hypothesis to explain ‘surfers’ myelopathy’ is that the blood vessel feeding the spinal cord was pinched or twisted due to the hyperextension of the spine on the surfboard. The advice then is for surfers to sit on their boards whilst waiting for a wave, only getting on their stomach when ready to paddle out and catch it. This way, surfers are avoiding putting their spine in a hyperextended position that could precipitate such a devastating spinal cord injury.
Treating SCI in Surfers
There is also a suggestion the the artery supplying blood to the spinal cord may be a different size and lay in a slightly altered position when the back is hyperextended in some people, creating a higher risk of ischaemia. Treating the patients has proved difficult as the ischaemic injury had already occurred by the time they were seen in the hospital. One patient underwent lumbar drainage to try to decompress the spine but this had no effect.
Blood Pressure and Neurologic Injury
Although increasing blood pressure can work to improve recovery in cases of nerve injury these patients appeared to have a better prognosis when their blood pressure was a little lower. The two patients with the best improvement had blood pressure of 70 mm Hg compared to most patients with blood pressure over 85mm Hg. Raising blood pressure can worsen oedema and lead to compression and secondary spinal cord injury.
Steroids and SCI Treatments
Treatment with methylprednisolone did not result in any symptom improvement and Dr Chang notes that the use of this treatment is sporadic after changes in guidelines for managing SCI. Such treatment appears more likely to have harmful side-effects than be of clinical benefit. Many of the patients in this study remain paralysed below the level of their injury, although some have improved over time. Patients should have traumatic fracture ruled out after such symptoms arise from surfing, along with a detailed medical history, neurologic examination and an MRI.
Spine Degeneration and Acute Neck Injury in Surfers
Spinal cord compression in surfers can result from cumulative injury, spine degeneration and spinal stenosis after carrying a surfboard over many years but this worrying study into ‘surfers’ myelopathy’ highlights a real risk for novice surfers who may consider themselves free of such concerns. Paralysing neck injuries when surfing may not be a result of spectacular wipeouts then but, instead, be due to lengthy waits for the perfect wave whilst lying in a position that hyperextends the spine.
Cherylee W.J. Chang, Daniel J. Donovan, Leon K. Liem, Kristine H. O’Phelan, Deborah M. Green, Sarice Bassin, Susan Asai, Surfers’ myelopathy
A case series of 19 novice surfers with nontraumatic myelopathy, Neurology November 27, 2012 vol. 79 no. 22 2171-2176 .
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