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Neurology India, Vol. 59, No. 5, September-October, 2011, pp. 788-789 Letter to Editor Multiple contiguous isolated spinous process fracture (Clay-Shoveler's fracture) of the cervicodorsal spine Alok Umredkar, Sukumar Sura, Sandeep Mohindra Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India PMID: 22019684 DOI: 10.4103/0028-3886.86579 Clay-Shoveler's fracture is an avulsion type fracture of the spinous processes of the lower cervical or upper thoracic vertebra. These fractures are common, with little clinical importance. [1] As these injuries are stable, they do not require surgical treatment. Isolated spinous process fracture should be viewed as a warning sign for more severe spinal injury and should be evaluated carefully to detect more severe spinal injuries. [2],[3] In this report, we presented a case of multiple contiguous isolated spinous process fracture of the cervical and dorsal spine. A 30-year-old male was admitted with history of road traffic accident while he was driving a car that collided against a tree. He had severe neck pain with radiation to the bilateral shoulder regions. Physical examination revealed tenderness over the posterior cervicodorsal spine. Neurological examination was normal. Cervical spine X-rays showed no fracture as the shoulder shadow obscured the lower cervical vertebrae [Figure - 1]a. Computed tomography (CT) scan of the cervicodorsal spine revealed contiguous isolated fractures of the spinous processes of C6 to T4 vertebrae [Figure - 1]b and c. Magnetic resonance imaging (MRI) scan showed the same contiguous fractures without any cord contusions [Figure - 2]. The patient was given muscle relaxant and analgesic therapy. Cervical immobilization was maintained for 4 weeks with a hard cervical collar. Fractures of the vertebral spinous process can result by several mechanisms such as a direct blow to the posterior aspect of the neck, cervical hyperextension and hyperflexion injuries and muscle and ligament stresses, generally due to shovel heavy loads. These injuries were described commonly at the beginning of the 20 th century, but have become relatively rare with the introduction of earth-moving machinery. [3] These types of injuries are also reported in athletes and golfers as a result of excessive stress and in transplant patients on steroids. [2],[3] In the present era, the common causes of spinous process fractures include falls and automobile or pedestrian accidents. In this patient, the mechanism of injury was hyperextension injury due to an automobile accident. The patient had hit a tree while driving with seat belt. The most common symptom of isolated spinous process fracture is pain. [3] Pain may radiate up to the head and down to the arms. Physical examination may reveal tenderness over the posterior spine. Neurological signs and symptoms may be associated with additional spinal injuries. The most useful imaging study for a Clay-shoveler's fracture is radiography. Plain X-ray may show a double spinous process shadow at the affected level on the antero-posterior views and downward displacement of the fractured bone fragment (spinolaminar breach sign) on lateral views. [4] CT and MRI of the cervical spine may be useful for detecting more serious fractures and soft tissues injuries of the spine. MRI is especially useful in the demonstration of ligament disruption. On MRI, anterior longitudinal ligament and anterior annulus fibrosus injuries are compatible findings with hyperextension injuries. [4] Isolated spinous fractures are most frequently seen at T-1, followed by C-7, T-2, T-3 and C-6. In more than 16% of the injuries, one spinous process is involved. [1],[3] Our patient also had contiguous isolated fracture of the spinous process of C-6 to T-4 vertebrae. The number of involved spinous processes may provide important clues regarding the severity of trauma. More severe trauma is likely to be accompanied by additional injuries. These injuries are stable fractures, although they may be painful. In most patients, immobilization of the neck by means of a collar and restriction of physical activity for 4-6 weeks frequently result in pain relief, but healing of the fractures does not usually occur. [3] Surgical removal of fracture is rarely indicated. Occasionally, fractures that produce significant pain and temporary disability may require surgical intervention. [1] References
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