Surfer's Myelopathy: A Rare Form of Spinal Cord Infarction in Novice Surfers: A Systematic Review.

BACKGROUND: Surfer's myelopathy is a rare, acute, atraumatic myelopathy that occurs in novice surfers. OBJECTIVE: To review the literature and to present an illustrative case. METHODS: Medical literature was queried for all reports of this condition, systematically abstracted, and analyzed. An illustrative case that provides the most definitive support for a vascular cause is presented. Treatment considerations based on prior cases and expert opinions are provided. RESULTS: Sixty-four cases of surfer's myelopathy have been reported to date. This atraumatic thoracic/conus medullaris myelopathy with only a 42% neurological recovery rate almost uniformly affects young, healthy, novice surfers who have no pre-existent spinal disease. Symptoms usually start with back pain and rapidly progress to complete or incomplete myelopathy. T2 magnetic resonance images show increased signal in the central spinal cord within 24 to 72 hours. Gadolinium enhancement and diffusion-weighted imaging are not helpful. Angiography has been underused. Angiogram in our case showed the absence of a right T12 radicular artery and no artery of Adamkiewicz, which, along with clinical findings, support the vascular origin theory. Incomplete cases often improve within 24 hours of onset, whereas no improvement has been reported for American Spinal Injury Association class A cases. Several acute interventions have been tried. Steroids are most common, and patients receiving steroids improved 55% of the time with no reported adverse effects. CONCLUSION: Surfer's myelopathy is a clinical entity associated with complete deficit in >50% of cases. Its prognosis is almost exclusively dictated by severity at presentation/nadir. Thus, publicizing this rare but serious condition (within and outside the medical literature) may be an effective intervention.

A comparison of computed tomography measures for diagnosing cervical spinal stenosis associated with myelopathy: a case-control study.

STUDY DESIGN: Retrospective comparative study. PURPOSE: To assess differences in computed tomography (CT) imaging parameters between patients with cervical myelopathy and controls. OVERVIEW OF LITERATURE: There is a lack of information regarding the best predictor of symptomatic stenosis based on osseous canal dimensions. We postulate that smaller osseous canal dimensions increase the risk of symptomatic central stenosis. METHODS: CT images and medical records of patients with cervical myelopathy (19 patients, 8 males; average age, 64.4±13.4 years) and controls (18 patients, 14 males; average age, 60.4±11.0 years) were collected. A new measure called the laminar roof pitch angle (=angle between the lamina) was conducted along with linear measures, ratios and surrogates of canal perimeter and area at each level C2-C7 (222 levels). Receiver-operator curves were used to assess the diagnostic value of each. Rater reliability was assessed for the measures. RESULTS: The medial-lateral (ML) diameter (at mid-pedicle level) and calculated canal area (=anterior-posterior.×ML diameters) were the most accurate and highly reliable. ML diameter below 23.5 mm and calculated canal area below 300 mm(2) generated 82% to 84% sensitivity and 67% to 68% sensitivity. No significant correlations were identified between age, height, weight, body mass in dex and gender for each of the CT measures. CONCLUSIONS: CT measures including ML dimensions were most predictive. This study is the first to identify an important role for the ML dimension in cases of slowly progressive compressive myelopathy. A ML reserve may be protective when the canal is progressively compromised in the anterior-posterior dimension.

Related and unrelated nonmyeloablative hematopoietic stem cell transplantation for malignant diseases.

Patients with advanced hematological malignancies ineligible for conventional myeloablative allogeneic hematopoietic stem cell transplantation (HSCT) due to advanced age or medical contraindications were enrolled in multi-center study to investigate the safety and efficacy of nonmyeloablative HSCT using a 2 Gy total body irradi ation (TBI)-based regimen. A total of 192 patients (median age 55) were treated with HLA-matched sibling peripheral blood stem cell (PBSC) grafts, and 63 patients (median age 53) received a 10 of 10 HLA-antigen matched unrelated donor (URD) HSCT (PBSC graft, n = 48; marrow graft, n = 15). Diagnoses included multiple myeloma (n = 61), myelodysplastic syndrome (n = 55), chronic myeloid leukemia (n = 31), non-Hodgkin lymphoma (n = 31), acute myeloid leukemia (n = 28), chronic lymphocytic leukemia (n = 24), Hodgkin Disease (n = 14). The conditioning regimen was fludarabine 30 mg/m2/d x 3 days and 2 Gy TBI. Ninety-five related HSCT patients received 2 Gy TBI without fludarabine. Postgrafting immunosuppression was combined mycophenolate mofetil an cyclosporine. Transplants were well tolerated with a median of 0 days of hospitalization in the first 60 days for eligible patients. For related HSCT recipients, median follow-up was 289 (100-1,188) days. Nonfatal graft rejection occurred in 6.8%. Of those with sustained engraftment, graft-versus-host disease (GVHD) occurred in 49% (33% grade II, 11% grade III, 5% grade IV). Day-100 non-relapse mortality was 6%. Overall, 59% (114/192) of patients were alive. The relapse/disease progression mortality was 18%, and non-relapse mortality was 22%. The projecte 2-year survival and progression-free survival were 50% and 40%. For the URD HSCT recipients, median follow-up was 190 (100-468) days. Graft rejection occurred in 27% (17/63) of patients, mostly in recipients of marrow grafts (9/15). Acute GVHD occurred in 63% (50% grade II, 13% grade III) of 46 engrafted patients. Chronic GVHD requiring therapy occurred in 50% of patients. Of the 63 URD HSCT patients, 54% were alive, 37% in CR, 3% PR, and 14% with disease progression or relapse. Related and unrelated nonmyeloablative HSCT is feasible and potentially curative in patients with advanced hematological malignancies who have no other treatment options.

Pathophysiology of lumbar disc degeneration: a review of the literature.

Lumbar disc degeneration occurs because of a variety of factors and results in a multitude of conditions. Alterations in the vertebral endplate cause loss of disc nutrition and disc degeneration. Aging, apoptosis, abnormalities in collagen, vascular ingrowth, loads placed on the disc, and abnormal proteoglycan all contribute to disc degeneration. Some forms of disc degeneration lead to loss of height of the motion segment with concomitant changes in biomechanics of the segment. Disc herniation with radiculopathy and chronic discogenic pain are the result of this degenerative process.

Guidelines for the use of discography for the diagnosis of painful degenerative lumbar disc disease.

OBJECT: Discography has been used as a diagnostic test in the evaluation of patients with recalcitrant low-back pain. Recently, its usefulness has been questioned because of the occurrence of false-positive results as well as the influence of psychological factors on test results. The purpose of this review is to establish the literature support for and against the use of discography. A search of the English-language literature published between 1966 and 2001 was performed. Papers were selected based on inclusion criteria described in the text, and the quality of information was graded using previously described methods. CONCLUSIONS: The authors propose a set of practice parameters based on the literature. Although the data were not judged adequate for the determination of a treatment standard, parameters for the use of discography are provided at a guideline and option level.

Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice.

OBJECT: The authors report a series of 22 patients in whom major complications developed after cervical spinal manipulation therapy (CSMT). A second objective was to estimate the regional incidence of these complications and to compare it with the very low incidences reported in the literature. METHODS: During a 5-year period, practioners at a single group neurosurgical practice in Tulsa, Oklahoma, treated 22 patients, who were markedly worse during, or immediately after, CSMT. The details of these cases are reported. The 1995 US Government National Census was used to define the regional referral population for Tulsa. The published data regarding the incidence of serious CSMT-related complications and the rate of CSMTs undertaken nationally were used to estimate the expected number of CSMT-related complications in the authors' region. The number (22 cases) reported in this series was used to estimate the actual regional incidence. Complications in the series included radiculopathy (21 cases), myelopathy (11 cases), Brown-Séquard syndrome (two cases), and vertebral artery (VA) occlusion (one case). Twenty-one patients underwent surgery. Poor outcomes were observed in three, outcome was unchanged in one, and 17 improved. The number of patients in this series exceeded the expected number for the region. CONCLUSIONS: Cervical spinal manipulation therapy may worsen preexisting cervical disc herniation or cause disc herniation resulting in radiculopathy, myelopathy, or VA compression. In cases of cervical spondylosis, CSMT may also worsen preexisting myelopathy or radiculopathy. Manipulation of the cervical spine may also be associated with higher complication rates than previously reported.

Bilateral locked facets of the lumbosacral spine: treatment with open reduction and transpedicular fixation.

BACKGROUND: A 23-year-old man was involved in a motor vehicle crash and found to have bilateral locked facets at L5-S1. His neurologic examination, radiographic workup, surgical management, postoperative care, and the relevant literature are discussed. DESIGN: Case report and literature review. RESULTS: This patient underwent solid fusion with anatomic alignment following open reduction and internal fixation. He made a good neurologic recovery. CONCLUSION: Early surgery, consisting of open reduction, fixation, and fusion, provides the best results in patients with lumbosacral fracture-dislocations.