Angiography in Surfer’s Myelopathy: A Case Report

Case Diagnosis: Surfer’s Myelopathy (SM)

Case Description or Program Description: A 30-year-old male with no significant medical history visiting Hawaii participated in his first surfing lesson. Throughout the lesson, he experienced gradually increasing throbbing low back pain, followed by progressive weakness and numbness of the legs. Within 30 minutes after the lesson, the patient could no longer move his legs. He was emergently transferred to the neurological ICU, where he presented with complete paraplegia and partial sensory impairment.

Setting: Tertiary care hospital.

Assessment/Results: T2-weighted MRI of the spine 3 hours after symptom onset demonstrated wide distribution of hyperintensity throughout the spinal cord from T6 to the conus medullaris. Angiography within 10 hours of symptom onset demonstrated disconnection of the right radicular artery at T12 from the anterior spinal artery (ASA). The left T12 crossed the midline to the right T12 arcade to supply the artery of Adamkiewicz (AKA). The craniad ASA did not fill from the AKA. The patient underwent 5 days of spinal perfusion pressure optimization with vasopressors and lumbar drain placement for intraspinal pressure monitoring and CSF drainage. T2 signal abnormalities resolved on 2-week follow-up. Three weeks post-injury, the patient began treadmill exercises in physical therapy. At 3 months, he was able to walk with assistance, and he continues to improve.

Discussion (relevance): SM is a rare, non-traumatic spinal cord injury that affects novice surfers. Current evidence suggests a vascular insult leads to spinal cord ischemia, but a precise understanding of the vascular injury remains poorly understood. Here we describe the first spinal angiography performed in the acute window.

Conclusions: This patient’s clinical features and MRI findings align with prior evidence supporting spinal ischemic stroke as the mechanism of SM. Spinal angiography suggests the T12 radicular artery may be implicated in the pathogenesis. Objective grading of the spinal vascular supply using spinal angiography may predict severity of symptoms and outcomes.