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

BACKGROUND: Surfer's myelopathy is a rare, nontraumatic spinal cord injury that predominantly affects young, novice surfers after prolonged spinal hyperextension. Owing to its low incidence and heterogeneous clinical and imaging features, the condition remains underrecognized, and its pathophysiology, diagnostic criteria, and optimal management strategies are not fully established. Increased awareness is particularly important in popular surfing destinations. CASE PRESENTATION: We report three cases of surfer's myelopathy in previously healthy young women who developed acute lower back pain followed by rapidly progressive bilateral lower-limb weakness and urinary retention shortly after recreational surfing. None reported trauma or preceding illness. Neurological examination revealed paraparesis with preserved upper-limb function, corresponding to American Spinal Cord Injury Association Impairment Scale grade D in all patients. Thoracic magnetic resonance imaging performed within 10-18 h after symptom onset demonstrated central intramedullary T2-weighted hyperintensity extending from the mid-thoracic spinal cord toward the conus medullaris, without evidence of compressive pathology. Management consisted of hemodynamic optimization, intravenous corticosteroids, spinal immobilization, and supportive care. All patients showed partial neurological improvement before discharge. CONCLUSION: Surfer's myelopathy should be considered in young patients presenting with acute nontraumatic paraparesis and autonomic dysfunction following surfing. Characteristic MRI findings support the diagnosis and help exclude alternative etiologies. Our cases support the applicability of broader diagnostic criteria and highlight the importance of early recognition, supportive management, and preventive education, particularly in regions with high surfing activity.