Non-traumatic spinal cord ischaemia - Surfer's myelopathy

A previously healthy surfer apprentice in his late 30s presented to our emergency department with acute paraplegia and loss of sensation in the lower limbs following sudden back pain during his third surfing lesson. The patient reported a hyperextension movement of the back while trying to stand up on the surfboard. On examination, he was classified as grade A on the American Spinal Injury Association (ASIA) Impairment Scale, with a sensory level at T10, hypotonic paraplegia, urinary retention and constipation. T2-weighted MRI revealed hyperintensity in the central spinal cord between T7 and T10 and a T11 focus of restricted diffusion compatible with spinal cord ischaemia. CT angiography of the thoracic and lumbar spine showed stenosis and occlusion of segmental arteries at the T11-T12, T12-L1 and L1-L2 levels. After extensive work-up, a diagnosis of surfer's myelopathy was made. The patient underwent antiplatelet treatment, high-dose methylprednisolone and early rehabilitation, but no major improvement was noted in the first 3 weeks. After 8 weeks of rehabilitation, the patient was able to dorsiflex and plantarflex the feet, as well as flex the legs, but remained unable to walk. Bilateral hypoaesthesia persisted and he had not regained anal or urinary sphincter control. He is now classified as ASIA D, and the MRI demonstrated complete resolution of the signal abnormalities after 8 weeks. Our case describes this non-traumatic entity with angiographic documentation of multiple vascular occlusions, which has rarely been reported in the literature and is thought to be secondary to arterial wall dissection and/or in situ thrombosis due to hyperextension and sudden movement of the back.