Injuries of the Head and Spine sustained while Surf Board Riding

Transcription

1 Injuries of the Head and Spine sustained while Surf Board Riding Poster No.: R-0175 Congress: RANZCR-AOCR 2012 Type: Educational Exhibit Authors: S. Dimmick, D. Brazier, P. Wilson, S. Anderson Keywords: Head and neck, Trauma, Musculoskeletal spine, MR, CT, Diagnostic procedure, Athletic injuries DOI: /ranzcraocr2012/R-0175 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply RANZCR's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold RANZCR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies,.ppt slideshows,.doc documents and any other multimedia files are not available in the pdf version of presentations. Page 1 of 21

2 Learning Objectives To understand the mechanisms of acute injuries sustained by surf board riders. To appreciate the spectrum and radiological imaging characteristics of head and spinal injuries sustained by surf board riders. Background Surf board riding is an iconic pastime. It is estimated that there are between 5 and 23 million surfers worldwide, including 2.4 million in America and 2 million in Australia (1). Surfing is a relatively safe sport with a reported incidence of injury ranging between 2.2 to 3.5 injuries per 1000 hours of surfing in recreational surfers and 6.6 injuries per 1000 hours of surfing in competitive (amateur and professional) surfers (2-5). This is comparable to other recreational activities, including long distance running (2.5 injuries per 1000 hours) (6). Surf board design and surfing accessories have evolved significantly over the past 20 years (figure 1). These innovations may increase the risk of injury, particularly to the head and facial regions. Images for this section: Page 2 of 21

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4 Fig. 1: The modern surfboard Page 4 of 21

5 Imaging Findings OR Procedure Details Traumatic Spinal Injuries Injuries to the cervical spine constitute between 3 and 10% of all acute surfing injuries (2-5). The majority of acute spinal injuries involve the cervical spine and are, in most cases, due to contact with the sea floor (7). Many different types of injuries occur in the cervical spine due to the variability in the mechanism of injury, which ranges from axial load, to hyper flexion or extension with or without a rotatory component, depending how the person's head makes contact with the seafloor and the force vector of the water (7) (figures 2 and 3). Violent mechanical force on the neck at the moment of impact on the sea floor may also result in traumatic dissection of the carotid or vertebral arteries (figure 4). Spinal cord contusions may occur in patients who have sustained an acute fracture or ligmentous injury or in patients with a stenotic spinal canal, either secondary to intervertebral disc prolapse or in patients with congenital cervical canal stenosis (figures 5-7). Although uncommon, injuries to the thoracic and lumbar spine also occur (figure 8). Soft tissue injuries of the spine Significant trauma to the soft tissue of the paravertebral region is most commonly secondary to a direct blow from the surfer's own board (muscle or subcutaneous contusion) or due to contact with the sea floor (muscle or ligamentous sprains) (figure 9). Atraumatic Acute Spinal Injuries - Surfers myelopathy Surfer's myelopathy is a rare nontraumatic ischaemia/infarction of the spinal cord. This entity occurs in novice surfers, typically during their first surfing lesson, in the absence of a traumatic event. The surfer develops back pain, progressing to paraparesis with sensory and urinary symptoms. The exact aetiology of surfers myelopathy has not been identified. Postulated causes include: Vasospasm of the artery of Adamkiewicz, avulsion of perforating arteries, tension on the spinal cord may cause ischemia or infarction of the cord in the watershed territory between the anterior and posterior spinal artery territories (8). Venous ischaemia due to increased retrograde venous pressure in the epidural venous plexuses while hyperextended on a surfboard (8). Page 5 of 21

6 Retrograde fibrocartilaginous embolization of intervertebral disc material (8). MRI in surfers myelopathy demonstrates oedema within the thoracic cord and/or conus on T2 or proton density sequences (figure 10). There is diffusion restriction within the cord in keeping with acute infarction. Rarely, haemorrhage may be present within the cord (7). MR angiography and formal spinal angiography are normal. Acute Head and Facial Injuries Common injuries to the head and facial region include: lacerations, soft tissue contusions, facial fractures and ocular trauma. Twenty-six percent of acute surfing injuries are to the head and face and make up 42% of emergency department presentations by surfers (2). Nathanson et al (2002) identified in all circumstances of facial bone fracture, the surfer was struck by a surfboard, their own in 66% of cases (4) (figure 11). Acute intra-cranial pathology such as subdural/subarachoid haemorrhage or cerebral contusions are rare. Lighter, shorter boards are now commonly used and provide greater maneuverability in the water. Modern surfboards however, are potential injurious missiles to the surfer and other surfers in close proximity. Although protective devices have been designed and marketed, there is no evidence to document their role in injury reduction (9). These devices include: leg ropes, surfboard nose guards, helmets and protective eyewear. Leg ropes are universally used to ensure that surfer and board do not become separated after falling off, but may increase the risk of being struck and injured by one's own board during a "wipe out". Nose guards are designed to fit over the surfboard's nose to reduce the risk of ocular trauma, in particular, and other facial injuries. Globe rupture may be caused by blunt or penetrating trauma from the nose of the surfboard (figure 12). Chronic Pathology - Surfers ear Surfers ear is a term used to describe exostoses (bony outgrowths) that form in the external auditory canal in response to chronic exposure to cold water (10) (figure 13). The exostoses are usually asymptomatic, however, may cause conductive hearing Page 6 of 21

7 loss, frequent ear infections or pain. They are usually bilateral. A study by Wong and colleagues (1999) of 307 avid surfers demonstrated an overall prevalence of 73.5% of exostoses in the external auditory canal. Images for this section: Page 7 of 21

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9 Fig. 1: The modern surfboard Fig. 2: Sagittal bone reformations of a CT cervical spine in a 41 year old man who suffered a hyperextension injury when his head struck the sea bed. There is an avulsion fracture of the antero-inferior aspect of the C3 vertebral body. Page 9 of 21

10 Fig. 3: Sagittal CT images of the cervical spine (A and B) in an 18 year old male found unconscious in the surf. There is a grade 1/2 anterolisthesis of C3/4 and an associated unilateral fracture dislocation of the right C3/4 facet joint. Page 10 of 21

11 Fig. 4: Gadolinium enhanced MRA (A) and diffusion weighted MRI images (B and C) in a 68 year old man who suffered a hyperextension injury while surfing. He was vomiting and had left arm weakness. MRA shows complete occlusion of the left vertebral artery due to a dissection. The diffusion sequence demonstrates an acute infarct involving the left PICA territory. Page 11 of 21

12 Fig. 5: Sagittal T2 MRI image (A) and sagittal bone reformation of a cervical spine CT in a 38 year old man who was found unconscious after falling from his board. There is a haemorrhagic contusion of the cord at C6 with a small epidural haematoma. There is disruption and widening of the C6/7 intervertebral disc. Bilateral facet fractures of C6/7 were also identified (not shown). Page 12 of 21

13 Fig. 12: Sagittal CT image of a 53 year old man who suffered blunt trauma to his left orbit when he was struck by the nose of his surf board. The left globe has ruptured. There is an associated hyphaema. Page 13 of 21

14 Fig. 11: Coronal bone reformation of a facial bone CT in a 25 year old man who suffered blunt trauma after being struck by his own board. There is a minimally displaced fracture of the floor of the left orbit (white arrow). Page 14 of 21

15 Fig. 10: Sagittal T2 (A), axial T2 (B) and axial gradient recalled echo MRI images of the thoracic cord in an 18 year old man. After completing his first surfing lession, he developed rapidly progressive lower limb weakness and sensory loss. The images demonstrate extensive T2 high signal throughout the visualised cord. Given the history, this represents surfers myelopathy. Haemorrhage within the cord (C) is rare in this condition. Page 15 of 21

16 Fig. 9: Sagittal T2 MRI image with fat saturation in a 28 year old man who fell from his surfboard, striking his occiput on a sand bank and suffering a hyperflexion injury to the cervical spine. The image demonstrates oedema within the inter and supraspinous ligaments from C2/3 to C4/5 and oedema within the spinous process of C4. No discrete fracture was identified on CT. Page 16 of 21

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18 Fig. 8: Lateral lumbar spine radiograph in a 39 year old man who was "dumped" onto his head while surfing, followed by hyperflexion of his spine. There is a superior end plate fracture of the L1 vertebral body. Fig. 7: Sagittal (A) and axial (B) T2 weighted MRI images of the upper cervical spine in a 36 year old man who suffered an axial load when he struck is head on a sand bank after falling from his surf board. The images demonstrate a congenitally narrow central canal and a cord contusion at the level of the C3/4 intervertebral disc. Page 18 of 21

19 Fig. 6: Sagittal (A) and axial (B) T2 weighted MRI images in a 47 year old man who struck is head on the sea floor while surfing. The images demonstrate a focal right paracentral disc protrusion at C6/7 with an adjacent cord contusion. Page 19 of 21

20 Fig. 13: Axial CT image of the petrous temporal bones in a 29 year old surfer with conductive hearing loss. On the right there are large bony exostoses (black arrows) and fluid opacification of the middle ear cavity. On the left, there are small exostoses (white arrow). Page 20 of 21

21 Conclusion Although surfing is a relatively safe sport, injuries of the spine are potentially devastating and occur when the surfer makes contact with the sea floor. Head/facial injures are most commonly caused by contact with the surfer's own board. The spectrum and imaging characteristics of these surfing injuries to the head and spine have been presented. Personal Information References Nathanson A, Bird S, Dao L, Tam-Sing K. Competitive surfing injuries: a prospective study of surfing-related injuries among contest surfers. Am J Sports Med. 2007; 35(1): Taylor DM, Bennett D, Carter M, Garewal D, Finch CF. Acute injury and chronic disability resulting from surfboard riding. J Sci Med Sport. 2004; 7(4): Nathanson A, Haynes P, Galanis D. Surfing Injuries. Am J Emerg Med. 2002; 20(3): Lowdon BJ, Pateman NA, Pitman AJ. Surfboard-riding injuries. Med J Aust. 1983; 2(12): Lyshom J. Injuries in runners. Am J Sports Med. 1987; 15(2): Dimmick S, Brazier D, Wilson P, Anderson SE. Injuries of the spine sustained while surfboard riding. Accepted for publication - Emergency Radiology. January 13, Shuster A, Franchetto A. Surfer's myelopathy-an unusual cause of acute spinal cord ischemia: a case report and review of the literature. Emerg Radiol. 2011; 18(1): Dimmick S, Sutton C, Sheehan P, Brazier D, Wilson P, Anderson SE. Acute injuries and chronic pathology of the head and face associated with surf board riding. (unpublished data) 10. Wong BJ, Cervantes W, Doyle, K, Karamzadeh AM, Boys P, Brauel G, Mushtaq E. Prevalence of external auditory canal exostoses in surfers. Arch Otolarygol Head Neck Surg. 1999; 125: Page 21 of 21