Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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January 27, 2022
Acute Hyperextension “Surfer’s” Myelopathy
- Background:
- A history of spinal extension in the absence of vascular or infectious risk factors and in the setting of T2 hyperintensity confirms the diagnosis.
- The etiology is hypothesized to be transient arterial or venous spinal vessel compression during spine hyperextension leading to cord infarction, given some cases show diffusion restriction.
- Clinical Presentation:
- Cases are rare but typically young adults or children with a significant spinal hyperextension or multiple smaller extensions (such as when surfing) followed by acute bilateral leg weakness and urinary retention, who then improve rapidly without intervention. CSF analysis is normal.
- Key Diagnostic Features:
- Longitudinally extensive T2 hyperintensity in the lower thoracic cord
- In the limited literature, up to 60% of patients also have DWI signal change indicating possible infarction.
- Contrast enhancement is a variable finding and typically faint.
- Differential Diagnoses:
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Longitudinally extensive transverse myelitis: T2 hyperintensity, may show contrast enhancement, no restriction
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Spinal cord infarct: Restricted diffusion; usually in the anterior aspect of the cord
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Neuromyelitis optica: T1 hypointensity, T2 hyperintensity, and contrast enhancement of central gray matter affecting >3 vertebral segments
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Spinal dural arteriovenous fistula: Surface flow voids and enlarged vessels, diffuse T2 hyperintensity with cord edema, patchy enhancement
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Treatment:
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These cases are rarely reported in neurology and are even more scarce in pediatrics, with only 5 cases reported in patients <20 years old, but they represent a diagnosis with guarded but sometimes excellent prognosis that requires no medical management other than physical therapy.
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There have been case reports with a beneficial response to high-dose steroids, making this a treatment consideration in severely affected patients, but there are no studies to prove efficacy.
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