Introduction

Fractures of the cervical spinous processes are relatively rare injuries. Isolated cervical spinous processes fractures are even rarer ; most reported cases are case reports. Sixteen percent of isolated spinous processes fractures of the cervical spine involve more than one level [₅]. Isolated cervical spinous process fractures are commonly referred to as clay-shoveler's fractures: this is a misnomer.

X. Jordana et al. [₁₁] defined a clay-shoveler's fracture as ‘an oblique , vertical break that affects the spinous processes from C6 to T3, but is most commonly found to involve C7, or both C7 and T1, and occasionally only T1'. It is a mechanical or repetitive stress fracture [₄]. Occasionally, the fracture can be acute. They are generally considered stable injuries.

The purpose of this study is to define and analyze the spectrum of injuries associated with fractures of the cervical spinous processes and suggest management strategies.

Materials and Methods

Institutional setting: The study was done in a secondary tertiary institution.

Type of study: retrospective study, from March 2005 to March 2008.

Study population: All adult patients referred to the Spinal Unit over a three – year period. The information was obtained from clinical and Radiological records. No approval from the ethics committee is necessary for retrospective studies.

Figure 1

Table 1: Demographic data, associated injuries, cervical spinous process fractures and management

Figure 2

Results

Fractures of the cervical spinous processes affect patients in their third decade. Males outnumber females 8 to 1. The mechanisms of injuries were motor vehicle accidents (n = 14), fall from a height ( n = 1), gunshot wounds (n = 1), and others( 1 patient had a wall falling on him). The most commonly involved area of the cervical spine is the lower cervical spine ; 16 ( 94%) patients. Only one case involved the upper and lower cervical spine. There was one case of an isolated fracture of the cervical spine.

Sixteen patients ( 94%) had additional injuries to the vertebral column. Three patients had involvement of the upper thoracic spinous processes. The number of spinous processes involved varied from one to four per patient. Eight ( 47%) patients had injuries involving other areas of the body. The spectrum of injuries and definite management of the cervical spine are shown in the accompanying table.

Discussion

Fractures of the cervical spinous processes signify severe injury. The majority of additional injuries involve the vertebral column: cervical spine (n = 10), base of skull ( n = 3), cervico-thoracic ( n = 2), cervico-lumbar( n = 2), lumbar ( n = 1), and thoracic ( n = 1). Approximately half of the patients had injuries involving the areas of the body other than the vertebral column. Isolated spinous process fractures of the cervical spine are relatively rare : 1/17 ( 5.9%) in our study. The number of vertebral spinous process involvement gives no clue as to the stability of the cervical spine.

There are currently four recognized mechanisms of injury that can cause fractures of the cervical spine processes [ ₅,₃]: hyperextension , hyperflexion, direct blow, and repetitive stress. Fractures of the spinous processes due to a direct blow to the back of the neck, may have associated laminar fractures [₉]. These types of injuries may be unstable and present with delayed neurological deficits.

Spinous process fractures of the cervical spine are considered to be in the category of severe fracture-dislocations [ ₉]. They may be one aspect of a significant injury. Thorough investigations is mandatory especially if the mechanism of injury is considered high-risk. However, some spinous process fractures are caused by low-energy injuries and almost invariably stable injuries [ ₁,₂,₁₀]. These stable fractures may be symptomatic especially if there is non-union [ ₆, ₇].

The limitations of our study are; it is a retrospective study, and the number of cases are few.

Conclusion

Fractures of the cervical spinous processes may represent serious injuries. The number of involved spinous process fractures gives no indication about the stability of the cervical spine. Isolated cervical spinous processes are rare injuries.

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