Skip to main content

Advertisement

SpringerLink
Log in

Is Surfer’s myelopathy an acute hyperextension-induced myelopathy? A systematic synthesis of case studies and proposed diagnostic criteria

  • Review
  • Published:
Journal of Neurology Aims and scope Submit manuscript

Abstract

Background

Surfer’s myelopathy is a rare complication of spinal hyperextension originally described in novice surfers. However, reports from patients practicing different activities had risen.

Aim

To systematically synthesize the epidemiological and clinical evidence on acute hyperextension-induced myelopathy (“Surfer's myelopathy”) and propose new diagnostic criteria.

Methods

We systematically searched four databases for all observational and case studies on the topic. We performed a narrative synthesis to propose diagnostic criteria and tested the criteria retrospectively on the included cases. A case report is also presented.

Results

Forty-two articles reporting 104 cases (median age 19 years, slightly male predominance) were included. All cases reported a nontraumatic hyperextension event (58% after surfing). All of the cases presented pain of hyperacute onset. The most frequent clinical feature was bladder or bowel dysfunction (84%). The thoracic region was the most frequently affected (87%) with longitudinal involvement until the conus (67%). At discharge or follow-up, 52% partially recovered. We propose five diagnostic criteria with three levels of certainty (definite, probable, and possible): (1) nontraumatic spine hyperextension activity (in individuals with no pre-existent spinal disease); (2) hyperacute onset (with acute pain onset); (3) spinal cord injury clinic (motor, sensory, or autonomic deficit); (4) MRI findings with central spinal cord abnormalities (multiple segments); and (5) no other alternative diagnosis. We identified 88% definite and 12% probable/possible cases.

Conclusion

The acute hyperextension-induced myelopathy could occur not only during surfing but also during other activities. Therefore, increased awareness and education among sports communities and general physicians are needed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Availability of data and material

The supplementary material includes extra information. If more information is needed, please contact the corresponding authors.

Code availability

Non applicable.

References

  1. Thompson TP, Pearce J, Chang GZ, Madamba J (2004) Surfer’s myelopathy. Spine 29(16):E353–E356

    Article  PubMed  Google Scholar 

  2. Chang CWJ, Donovan DJ, Liem LK, O’Phelan KH, Green DM, Bassin S, Asai S (2012) Surfers’ myelopathy: a case series of 19 novice surfers with nontraumatic myelopathy. Neurology 79(22):2171–2176

    Article  PubMed  Google Scholar 

  3. Freedman-Brett AMDG, Rasmussen PA, Cage-Jason M, Benzel EC (2015) Surfer’s myelopathy: a rare form of spinal cord infarction in novice surfers: a systematic review. Neurosurgery 2015:78

    Google Scholar 

  4. González-Too-Konga SAGF, Vial-Undurraga F, López-Galleguillos M, Brunser-Rabovich A (2015) Surfer’s Myelopathy: two case reports in Chile and a literature review. J Neurol Sci 2015:357

    Google Scholar 

  5. Maharaj MM, Phan K, Hariswamy S, Rao PJ (2016) Surfer’s myelopathy: a rare presentation in a non-surfing setting and review of the literature. J Spine Surg (Hong Kong) 2(3):222–226

    Article  Google Scholar 

  6. Steinfeld Y, Keren Y, Haddad E (2018) Spinal cord injury with central cord syndrome from surfing. Spinal Cord Ser Cases 4:11

    Article  PubMed  PubMed Central  Google Scholar 

  7. Choi JH, Ha J-K, Kim CH, Park JH (2018) Surfer’s myelopathy : case series and literature review. Korean Neurosurg Soc 61:767

    Article  Google Scholar 

  8. Aviles-Hernandez I, Garcia-Zozaya I, DeVillasante JM (2007) Nontraumatic myelopathy associated with surfing. J Spinal Cord Med 30(3):288–293

    Article  PubMed  PubMed Central  Google Scholar 

  9. Shuster A, Franchetto A (2011) Surfer’s myelopathy-an unusual cause of acute spinal cord ischemia: a case report and review of the literature. Emerg Radiol 18(1):57–60

    Article  PubMed  Google Scholar 

  10. Albuja AC, Qaiser S, Lightner DD, Raslau FD, Zafar MS, Bernard PA, Baumann RJ (2017) Surfer’s myelopathy without surfing: a report of two pediatric patients. Spinal Cord Ser Cases 3:17008

    Article  PubMed  PubMed Central  Google Scholar 

  11. Reisner A, Chern JJ, Grattan-Smith JD, Gary MF, Palasis S, Little SB (2017) Letter: Surfer’s myelopathy: a rare form of spinal cord infarction in novice surfers: a systematic review. Neurosurgery 80(3):E213

    Article  PubMed  Google Scholar 

  12. Davis GA, Klug GL (2000) Acute-onset nontraumatic paraplegia in childhood: fibrocartilaginous embolism or acute myelitis? Child’s Nervous Syst 16(9):551–554

    Article  CAS  Google Scholar 

  13. Reisner A, Gary MF, Chern JJ, Grattan-Smith JD (2013) Spinal cord infarction following minor trauma in children: fibrocartilaginous embolism as a putative cause. J Neurosurg Pediatr 11(4):445–450

    Article  PubMed  Google Scholar 

  14. Teixeira S, Moser F, Kotton RH (2016) Imaging features and differentials in surfer’s myelopathy: a case report. Emerg Radiol 23(1):89–92

    Article  PubMed  Google Scholar 

  15. Nakamoto BK, Siu AM, Hashiba KA, Sinclair BT, Baker BJ, Gerber MS, McMurtray AM, Pearce AM, Pearce JW (2013) Surfer’s myelopathy: a radiologic study of 23 cases. AJNR Am J Neuroradiol 34(12):2393–2398

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Scatchard R, Alves Rosa J, Bowen P, Mortimer A, Sharples PM, Lux AL (2018) A case report: paediatric surfer’s myelopathy. Eur J Paediatric Neurol 22(1):199–202

    Article  Google Scholar 

  17. Green E, Zishan US, Robertson N, Papanikitas J, Yanny S, Hughes R, McKean D (2018) Non-traumatic myelopathy associated with prolonged hyperextension during swimming: an unusual variation of Surfer’s Myelopathy. Spinal Cord Ser Cases 4:22

    Article  PubMed  PubMed Central  Google Scholar 

  18. Wadia S, Padmanabhan P, Moeller K, Rominger A (2015) Pediatric Surfer’s Myelopathy. J Emerg Med 49(5):e143-145

    Article  PubMed  Google Scholar 

  19. Mohr JPBO, Barnett HJ (1998) Spinal cord ischemia. In: Mohr JPSB, Yatsu FM (ed) Stroke pathophysiology, diagnosis, and management. Churchill Livingstone, Philadelphia, p 423

  20. Dillen WL, Hendricks BK, Mannas JP, Wheeler GR (2018) Surfer’s myelopathy: a rare presentation in a teenage gymnast and review of the literature. J Clin Neurosci 50:157–160

    Article  PubMed  Google Scholar 

  21. Shukla V, Kleppe S, Walters W (2018) Surfer’s Myelopathy in Pediatric population. Neurology 2018:90

    Google Scholar 

  22. Takakura T, Yokoyama O, Sakuma F, Itoh R, Romero RR (2013) Complete paraplegia resulting from surfer’s myelopathy. Am J Phys Med Rehabil 92(9):833–837

    Article  PubMed  Google Scholar 

  23. Aoki M, Moriizumi S, Toki M, Murakami T, Ishiai S (2013) Rehabilitation and long-term course of nontraumatic myelopathy associated with surfing. Am J Phys Med Rehabil 92:828–832

    Article  PubMed  Google Scholar 

  24. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6(7):e1000100

    Article  PubMed  PubMed Central  Google Scholar 

  25. Riley DS, Barber MS, Kienle GS, Aronson JK, von Schoen-Angerer T, Tugwell P, Kiene H, Helfand M, Altman DG, Sox H (2017) CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol 89:218–235

    Article  Google Scholar 

  26. Bickley CRJ, Belyea MCM, Harpstrite CRJK, Kyong S, Min M (2021) Surfing injuries: a review for the orthopaedic surgeon. JBJS Rev 9:4

    Article  Google Scholar 

  27. Murad MH, Sultan S, Haffar S, Bazerbachi F (2018) Methodological quality and synthesis of case series and case reports. BMJ Evid-Based Med 23(2):60–63

    Article  PubMed  PubMed Central  Google Scholar 

  28. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, Britten N, Roen K, Duffy S (2006) Guidance on the conduct of narrative synthesis in systematic reviews: a product from the ESRC Methods Programme

  29. Me KMKAWK (2010) A case of surfers’ myelopathy. Am J Clin Med 2010:7

    Google Scholar 

  30. Alzahrany M, McVeigh S, Parks N (2019) Paraplegia on vacation: Surfer’s myelopathy variant. Neurology 92:15

    Google Scholar 

  31. Bakhsheshian J, Chang KE, Strickland BA, Donoho DA, Christian EA (2016) Teaching neuro images: acute neurologic deficits due to surfer’s myelopathy. Neurology 87(17):e206–e207

    Article  PubMed  Google Scholar 

  32. Bouattour N, Farhat N, Sakka S, Hdiji O, Daoud S, Moalla K, Damak M, Mhiri C (2021) An unusual case of acute myelopathy: Surfer’s myelopathy in a teenage gymnast. Rev Neurol 177(6):717–719

    Article  CAS  PubMed  Google Scholar 

  33. Choi J, Seok HY, Kim Y, Kim BJ (2017) Surfer’s myelopathy mimicking infectious myelitis. J Clin Neurol (Seoul, Korea) 13(2):207–208

    Article  Google Scholar 

  34. Chung HY, Sun SF, Wang JL, Lai PH, Hwang CW (2011) Non-traumatic anterior spinal cord infarction in a novice surfer: a case report. J Neurol Sci 302(1–2):118–120

    Article  PubMed  Google Scholar 

  35. Cipriano K, Mansfield JT, Batal H, Gosai E (2020) Nontraumatic acute hyperextension myelopathy associated with weightlifting "nontraumatic hyperextension myelopathy. Am J Phys Med Rehabil 2020:5

    Google Scholar 

  36. Dhaliwal PP, Cenic A, Eesa M, du Plessis S (2011) An unusual case of myelopathy: surfer’s myelopathy. Can J Neurol Sci 38(2):354–356

    Article  CAS  PubMed  Google Scholar 

  37. Fessa CK, Lee BS (2012) An Australian case of surfer’s myelopathy. Clin J Sport Med 22(3):281–283

    Article  PubMed  Google Scholar 

  38. Gilbert C, Kirshblum S, Miller A, Nieves J (2020) Surfer’s myelopathy: an atypical case presentation. Spinal Cord Ser Cases 6(1):46

    Article  PubMed  PubMed Central  Google Scholar 

  39. Karabegovic A, Strachan-Jackman S, Carr D (2011) Surfer’s myelopathy: case report and review. CJEM 13(5):357–360

    Article  PubMed  Google Scholar 

  40. Klontzas ME, Hatzidakis A, Karantanas AH (2015) Imaging findings in a case of stand up paddle surfer’s myelopathy. BJR Case Rep 1(1):20150004

    CAS  PubMed  PubMed Central  Google Scholar 

  41. Levy R, Guimaraes C, Partap S (2020) Acute hyperextension “surfer’s” myelopathy in a gymnast: bending over backwards for diagnosis. Neurology 94:15

    Google Scholar 

  42. Lieske J, Cameron B, Drinkwine B, Goretzke S, Alemi L, Needham K, Ventura J, Ho VT, La Barge DV (2011) Surfer’s myelopathy-demonstrated by diffusion-weighted magnetic resonance imaging: a case report and literature review. J Comput Assist Tomogr 35(4):492–494

    Article  PubMed  Google Scholar 

  43. Lin CY, Fu JH, Li SC, Lai PH (2012) Surfer’s myelopathy. QJM 105(4):373–374

    Article  PubMed  Google Scholar 

  44. Matarazzo M, Castaño Leon A, Labiano Fontcuberta A, Zurita Santamaria J, Ramos Gonzalez A (2012) Surfer’s myelopathy, first European case. J Neurol 259(1):S118

    Google Scholar 

  45. Nakano H, Yamamoto D, Yamagami H, Sekine I, Ofuchi H (2019) Paraplesia after surfing in a young female novice surfer: a case report on surfer’s myelopathy. Acute Med Surg 6(3):312–315

    PubMed  PubMed Central  Google Scholar 

  46. Rider E, Gold CA (2018) Young Man With Paraparesis. Ann Emerg Med 72(3):e19–e20

    Article  PubMed  Google Scholar 

  47. Too-Kong SG, Grau FA, Undurraga FV, Galleguillos ML, Rabovich AB (2015) Surfer’s Myelopathy: two case reports in Chile and a literature review. J Neurol Sci 357:E379–E379

    Article  Google Scholar 

  48. Yang MX, Ault MJ (2019) A paralyzing vacation: surfer’s myelopathy. Am J Med 132(11):1289–1291

    Article  PubMed  Google Scholar 

  49. Wang Y, Zhu F, Zeng L, Wang S, Liu Y, Yang L, Zhao W, Zhou Y, Wu Z, Li M et al (2021) Surfer myelopathy in children: a case series study. World Neurosurg 148:e227–e241

    Article  PubMed  Google Scholar 

  50. Yang SY, Lee JM (2020) Golfer’s myelopathy: is it like surfer’s myelopathy? Ann Indian Acad Neurol 23(5):714–715

    PubMed  PubMed Central  Google Scholar 

  51. Dimmick S, Brazier D, Wilson P, Anderson SE (2013) Injuries of the spine sustained whilst surfboard riding. Emerg Radiol 20(1):25–31

    Article  PubMed  Google Scholar 

  52. Barber K, Sarmiento C, Niehaus W (2020) Hyperextension-induced dorsal cord syndrome: case presentation. PM R 12(5):518–521

    Article  PubMed  Google Scholar 

  53. Bouattour N, Farhat N, Sakka S, Hdiji O, Daoud S, Moalla K, Damak M, Mhiri C (2021) An unusual case of acute myelopathy: Surfer’s myelopathy in a teenage gymnast. Rev Neurol (Paris) 176:717–719

    Article  Google Scholar 

  54. Cipriano K, Mansfield JT, Batal H, Gosai E (2020) Nontraumatic acute hyperextension myelopathy associated with weightlifting nontraumatic hyperextension myelopathy. Am J Phys Med Rehabil 2020:5

    Google Scholar 

  55. Zalewski NL, Rabinstein AA, Krecke KN, Brown RD, Wijdicks EFM, Weinshenker BG, Kaufmann TJ, Morris JM, Aksamit AJ, Bartleson JD (2019) Characteristics of spontaneous spinal cord infarction and proposed diagnostic criteria. JAMA Neurol 76(1):56–63

    Article  PubMed  Google Scholar 

  56. World Health Organization, International Spinal Cord Society (2013) International perspectives on spinal cord injury. World Health Organization

  57. Robertson CE, Brown RD Jr, Wijdicks EFM, Rabinstein AA (2012) Recovery after spinal cord infarcts: long-term outcome in 115 patients. Neurology 78(2):114–121

    Article  PubMed  PubMed Central  Google Scholar 

  58. Mariano RFE, Weinshenker BG et al (2018) A practical approach to the diagnosis of spinal cord lesions. Pract Neurol Epub 18:187–200

    Article  Google Scholar 

  59. RW H (2006) Spinal vascular disorders. In: Resonance imaging of the brain and spine. SW A (ed) Philadelphia Lippincott, p 1387

  60. Cheng MY, Lyu RK, Chang YJ, Chen CM, Chen ST, Wai YY, Ro LS (2009) Concomitant spinal cord and vertebral body infarction is highly associated with aortic pathology: a clinical and magnetic resonance imaging study. J Neurol 256(9):1418–1426

    Article  PubMed  Google Scholar 

  61. Weidauer S, Nichtweiß M, Hattingen E, Berkefeld J (2015) Spinal cord ischemia: aetiology, clinical syndromes and imaging features. Neuroradiology 57(3):241–257

    Article  PubMed  Google Scholar 

  62. Walters BC, Hadley MN, Hurlbert RJ, Aarabi B, Dhall SS, Gelb DE, Harrigan MR, Rozelle CJ, Ryken TC, Theodore N (2013) Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery 60(CN_suppl_1):82–91

    Article  PubMed  Google Scholar 

Download references

Funding

The present study was self-funded by the authors.

Author information

Authors and Affiliations

  1. Servicio de Neurología, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigación (OADI), Hospital Daniel Alcides Carrión, Callao, Perú

    Carlos Alva-Díaz, Tatiana Metcalf, Nicanor Mori & Roberto Romero-Sanchez

  2. Grupo de Investigación Neurociencia, Efectividad Clínica y Salud Pública, Universidad Científica del Sur, Lima, Perú

    Carlos Alva-Díaz, Ethel Rodriguez-López & Victor Velásquez-Rimachi

  3. Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Perú

    Ethel Rodriguez-López, Angélica López-Saavedra & Nicanor Mori

  4. Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Perú

    Ethel Rodriguez-López, Angélica López-Saavedra, Tatiana Metcalf, Cristian Morán-Mariños, Victor Velásquez-Rimachi & Wilfor Aguirre-Quispe

  5. Unidad de Investigación en Bibliometría, Universidad San Ignacio de Loyola, Lima, Perú

    Cristian Morán-Mariños

  6. Facultad de Medicina, Universidad Nacional Federico Villarreal, Lima, Peru

    Alba Navarro-Flores

  7. Instituto Nacional de Ciencias Neurológicas, Lima, Peru

    Wilfor Aguirre-Quispe

  8. Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Emad S. Shaikh & Kevin Pacheco-Barrios

  9. Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, 550 La Fontana Avenue, La Molina, 15024, Lima, Perú

    Kevin Pacheco-Barrios

Authors
  1. Carlos Alva-Díaz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ethel Rodriguez-López
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Angélica López-Saavedra
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Tatiana Metcalf
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Cristian Morán-Mariños
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Alba Navarro-Flores
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Victor Velásquez-Rimachi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Wilfor Aguirre-Quispe
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Emad S. Shaikh
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Nicanor Mori
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Roberto Romero-Sanchez
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Kevin Pacheco-Barrios
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

A-DC, L-SA, R-LE, and NM designed the case report; M-MC and N-FA provided the method to develop the systematic review; L-SA, R-LE, and N-FA independently screened titles and abstracts for relevance, assessed full texts for inclusion, and carried out data extraction; M-MC, A-DC, and P-BK conducted the formal analysis; A-DC, R-LE, L-SA, M-MC, N-FA, and P-BK drafted the manuscript; A-DC, V-RV, AW, ESS, MN, and R-SR provided clinical corrections; A-DC, P-BK, V-RV, and MT revised the manuscript and did systematic review; MT, ESS, N-FA, and P-BK helped in the translation, editing, and proofing of the manuscript and contributed to the method report and systematic review. All authors provided critical revisions to the manuscript.

Corresponding author

Correspondence to Kevin Pacheco-Barrios.

Ethics declarations

Conflicts of interest

The authors declare no conflicts of interest.

Ethics approval

For reporting the clinical case, the authors receive approval from the Institutional Review Board of “Daniel Alcides Carrión” Hospital, Lima, Peru.

Consent to participate

The index patient provided his informed consent to participate in the case report.

Consent for publication

The patient provided consent for publication of the case report.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 114 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Alva-Díaz, C., Rodriguez-López, E., López-Saavedra, A. et al. Is Surfer’s myelopathy an acute hyperextension-induced myelopathy? A systematic synthesis of case studies and proposed diagnostic criteria. J Neurol 269, 1776–1785 (2022). https://doi.org/10.1007/s00415-021-10775-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00415-021-10775-4

Keywords

Search

Navigation