Research report: Surfer’s myelopathy in Bali: a case series of three patients and review of the pathophysiology, proposed diagnostic criteria, and treatment

Three previously healthy young women developed sudden weakness in both legs and an inability to urinate within hours of surfing in Bali, and a new case series published in Chinese Neurosurgical Journal argues their stories should serve as a warning to anyone picking up a surfboard for the first time. The report, published on 15 September 2026, describes three cases of surfer’s myelopathy, a rare nontraumatic spinal cord injury that predominantly affects young, novice surfers after prolonged spinal hyperextension. Because the condition is so uncommon, with fewer than 100 cases reported since it was first described in 2004, it remains underrecognized, and its pathophysiology, diagnostic criteria, and optimal management strategies are not fully established. The authors, Mira Yuniarti, Lorentia Harisusanti, Jeffrey Tanudjaja, and Gilbert Sterling Octavius, combined their three cases with a literature review to summarize the current state of knowledge in the field.

The first patient was a 24-year-old Korean woman who presented approximately 15 hours after the onset of progressive bilateral lower-limb weakness that began the previous evening. She had surfed for approximately 3 hours earlier that morning, and after roughly 3 hours in the water she developed acute lower back pain followed by progressive weakness in both legs and urinary retention. Neurological examination showed reduced motor strength in the lower extremities, with a Medical Research Council grade of 4/5 in the right lower limb and 3/5 in the left, while upper-extremity strength remained normal. Sensory testing demonstrated hypoesthesia below the T9 level, and she required catheterization for acute urinary retention. Cerebrospinal fluid analysis and other laboratory investigations were within normal limits.

Contrast-enhanced thoracic magnetic resonance imaging performed 18 hours after symptom onset, using multiplanar T1-weighted, T2-weighted, and short tau inversion recovery sequences, revealed a mildly hyperintense intramedullary lesion at the T6–T7 and T7–T8 levels, consistent with short-segment myelopathy. Post-contrast imaging showed no enhancement. The patient received intravenous corticosteroids and supportive care, and she showed partial neurological improvement before discharge after 7 days, still at AIS grade D. The second case involved a 20-year-old previously healthy Chinese woman who developed acute lower back pain while surfing, followed 6 hours later by progressive bilateral lower-limb weakness and urinary retention. Her assessment showed bilateral lower-extremity weakness at MRC grade 4 bilaterally with preserved upper-extremity function, and she was also classified as AIS grade D on admission.

Her non-contrast thoracolumbar MRI, performed 10 hours after onset, revealed a central T2 hyperintense lesion extending from T8 to T12, suggestive of a long-segment myelopathy. She received supportive treatment including corticosteroids, hemodynamic optimization, and spinal immobilization, with partial neurological improvement before discharge. The third patient was a 25-year-old previously healthy Caucasian woman who arrived at the emergency department 7 hours after the onset of acute lower back pain followed by rapidly progressive bilateral lower-limb weakness and urinary retention. Her symptoms began after her first surfing lesson. Examination revealed bilateral lower-extremity weakness at MRC grade 4 with preserved upper-extremity motor function and reduced sensation below approximately the T9 dermatome, and she too required catheterization for urinary retention and was graded AIS D.

Non-contrast thoracolumbar spine MRI performed 12 to 13 hours after onset in the third patient demonstrated a central intramedullary T2 hyperintense lesion extending from the T7–T8 to the T10–T11 levels, without evidence of compressive pathology, findings the authors considered consistent with surfer’s myelopathy. She received supportive treatment including corticosteroids, hydration, blood pressure optimization, and spinal immobilization, again with partial neurological improvement before discharge. Across all three cases, neurological symptoms developed within hours after surfing, and MRI was performed within 10 to 18 hours of symptom onset, a temporal pattern the authors note is consistent with previous reports. None of the patients reported trauma or preceding illness, and all had been previously healthy.

The most widely accepted explanation for the condition is ischemic: sustained spinal hyperextension is hypothesized to cause vascular compromise and subsequent ischemia of the distal spinal cord, rather than direct traumatic injury. Surfer’s myelopathy is hypothesized to result from sustained hyperextension of the spine, leading to vascular compromise and subsequent ischemia of the distal spinal cord. The clinical presentation together with characteristic imaging findings supports a vascular etiology involving dynamic arterial compression, vasospasm, or thrombotic infarction of the great anterior radicular artery of Adamkiewicz. This artery typically originates from an inferior intercostal or lumbar artery between T9 and L2, ascends to anastomose with the anterior spinal artery, and supplies the inferior portion of the spinal cord. Suggested risk factors include a slender body build with relatively underdeveloped musculature, dehydration, and a hypercoagulable state associated with prolonged travel. Infarction of this vessel, as seen in aortic aneurysm injury or repair, produces a similar vascular distribution of spinal cord injury on MRI. Alternative mechanisms, including fibrocartilaginous embolism, arterial dissection, venous infarction, and mechanical cord compression, have been proposed but remain unproven, and the ischemic hypothesis remains the most widely accepted.

Imaging plays a central role in diagnosis. Spinal MRI findings in surfer’s myelopathy typically show longitudinally extensive T2-weighted hyperintensity extending from the mid-thoracic spine, approximately T5 to T10, to the conus medullaris within 2 to 24 hours of symptom onset, often accompanied by variable fusiform cord enlargement in a pencil-like fashion. The differing extents of thoracic cord involvement may reflect anatomical variability in the origin of the artery of Adamkiewicz, which arises from T5 to T8 in approximately 15 percent of individuals, from T9 to T12 in about 75 percent, and from L1 to L2 in the remaining 10 percent. The role of diffusion-weighted imaging remains uncertain; although diffusion restriction may indicate acute spinal cord ischemia, inconsistent findings and technical limitations prevent its routine use. The diagnosis hinges on the rapid onset of signs and symptoms after a known insult, with all other plausible mechanisms excluded. The most frequently reported manifestations include back pain, urinary dysfunction such as incontinence or retention, paraplegia or paraparesis, lower extremity weakness, and sensory deficits, with additional findings that may include hypesthesia, hypoalgesia, and hyperesthesia. All three patients in this series fulfilled the recently proposed Alva-Díaz diagnostic criteria, which were based on the characteristic clinical presentation, MRI findings, and exclusion of compressive, infectious, and inflammatory causes.

Distinguishing the condition from its mimics is critical. The principal differential diagnosis for MRI findings confined to the gray matter is acute spinal cord infarction, which remains the closest radiological differential. Other important considerations include transverse myelitis associated with neuromyelitis optica or autoimmune disorders such as systemic lupus erythematosus, as well as multiple sclerosis. Although these conditions often present with preceding inflammatory signs and symptoms and show differing imaging characteristics, their initial presentations may be severe and radiologically similar to surfer’s myelopathy. On the treatment side, management is largely supportive and includes maintenance of spinal cord perfusion, rehabilitation, and individualized corticosteroid use, with intense rehabilitation and physical therapy in a qualified spinal cord injury center described as the hallmark of clinical therapy. Intravenous corticosteroids have been commonly used as the main treatment despite the lack of supporting evidence, and their administration was associated with an improvement of at least one AIS grade in 55 percent of reported cases. However, the American Academy of Neurological Surgeons advises against the use of methylprednisolone in acute spinal cord injury, and if the pathophysiology is ischemic, steroids would not be expected to be effective.

Prognosis remains incompletely defined and appears to vary widely. Case reports suggest that patients presenting with milder symptoms and less severe weakness may demonstrate early neurological improvement during hospitalization or rehabilitation, but many patients still require assistive devices for mobility at discharge, and the extent of long-term functional recovery remains variable. Patients presenting with complete paraplegia generally have poorer recovery, whereas milder deficits are associated with better functional outcomes after rehabilitation. A key limitation of the new series is the absence of long-term clinical and radiological follow-up: all three patients were international travelers who returned to their home countries shortly after hospital discharge, and subsequent follow-up evaluations could not be obtained despite attempts through available contact channels, so the long-term neurological outcome and potential radiological evolution of the spinal cord lesions could not be assessed.

The authors argue that prevention is the most effective approach to managing this condition, in the form of public service announcements and increased awareness among physicians, novice athletes, and surfing schools. First-time surfers, defined as those with no prior experience on a surfboard before the day of injury, account for approximately 89.5 to 100 percent of novice surfers reported across published studies, and the incidence has been estimated at 2.2 to 6.6 injuries per 1000 hours of surfing, predominantly affecting younger individuals with a mean age of 25.9 years and an age range spanning from 15 to 46 years. Accumulating evidence also suggests the condition can occur in children and adolescents and is not intrinsically related to surfing itself but rather to prolonged spinal hyperextension and associated vascular compromise, despite its name. For a destination like Bali, the authors conclude, increased awareness among clinicians, radiologists, and surfing instructors may facilitate earlier diagnosis and promote preventive strategies.

Subject of Research: Surfer's myelopathy, a rare nontraumatic spinal cord injury affecting novice surfers after prolonged spinal hyperextension

Article Title: Surfer’s myelopathy in Bali: a case series of three patients and review of the pathophysiology, proposed diagnostic criteria, and treatment

Article References: Yuniarti, M., Harisusanti, L., Tanudjaja, J., & Octavius, G. S. (2026). Surfer’s myelopathy in Bali: a case series of three patients and review of the pathophysiology, proposed diagnostic criteria, and treatment. Chinese Neurosurgical Journal, 12(1), Article 30. https://doi.org/10.1186/s41016-026-00450-w

Image Credits: AI Generated

DOI: 10.1186/s41016-026-00450-w

Keywords: surfer's myelopathy, spinal cord injury, Bali, case series, spinal hyperextension, artery of Adamkiewicz, MRI, paraparesis, novice surfers, ischemia, corticosteroids, Chinese Neurosurgical Journal