Isolated thoracic spinous process fractures involving multiple adjacent vertebral segments are a rare occurrence in the setting of high-energy trauma. These findings should prompt further investigation to exclude other concomitant osseous or ligamentous injuries. Evaluation by computed tomography is often most useful to detect these fractures. Proper treatment of extensive multilevel injury is poorly defined in the literature. In our experience, conservative management consisting of initial bracing with graduated lifting restrictions has produced excellent functional results.
The term “Clay-Shoveler’s fracture” was originally coined in 1940 to describe isolated spinous process fractures occurring from C6-T3 in Western Australian laborers [
A 53-year-old male was involved in a motorcycle collision at a speed of approximately 40 mph. Physical exam was significant for right-sided paraspinal tenderness in the thoracic region. He had no neurologic deficits. Computed tomography (CT) revealed thoracic spinous process fractures within T5–T10 without evidence of vertebral body injury, extension into the lamina, or ligamentous compromise (Figure
(a) Sagittal computed tomography (CT) image demonstrating thoracic spinous process fractures (arrows) spanning from T5 to T10. (b) Axial CT showing select (T6, T9, and T10) spinous process fractures (arrows). No evidence of vertebral body or intralaminar extension is noted.
Sagittal (a) and anteroposterior (b) plain film in thoracolumbar sacral orthosis brace at 10 weeks after the initial injury, demonstrating good osseous union and well-maintained sagittal alignment.
A 53-year-old man without a helmet lost control of his motorcycle and collided with a guardrail. He had loss of consciousness and an initial Glasgow coma scale score of 12. Physical exam revealed no gross abnormalities of the spine; however he expressed significant left-sided paraspinal tenderness in the thoracic region. CT of his spine revealed isolated fractures of the thoracic spinous processes within T6–T10 without any other evidence of spine pathology (Figure
(a) Sagittal CT demonstrating thoracic spinous process fractures (arrows) spanning from T6 to T10. (b) Axial CT showing select (T6, T9, and T10) spinous process fractures (arrows). No evidence of vertebral body or intralaminar extension is noted.
Isolated thoracic spinous process fractures involving five or more contiguous vertebrae are rarely encountered in the orthopaedic literature. These fractures often occur in conjunction with other bony or soft tissue injuries of the vertebral column. The two aforementioned cases almost double the reported literature on this specific fracture pattern. Although this pattern of injury has been referred to elsewhere as “Clay-Shoveler’s fracture,” it should be considered a different entity based on the energy mechanism, level, and extent of contiguous segment involvement. Meyer et al. [
Other authors have recently reported cases of extensive multilevel spinous process fractures involving the cervicothoracic junction [
Isolated thoracic spinous process fractures are stable injuries, which are routinely treated with conservative therapy. Even in the setting of multilevel contiguous fractures, excellent functional outcomes are commonplace with nonoperative therapy. Conservative treatment with a TLSO brace for 6 weeks with graduated lifting restrictions for up to 10 weeks has produced great results in our experience, with both patients going on to pain-free full recovery. Persistent and focal pain over the spinous processes beyond this time period should raise concern for a symptomatic pseudoarthrosis. It is well documented that spinous process fractures infrequently achieve osseous union [
Isolated thoracic spinous process fractures in the setting of high-energy trauma are a rare occurrence. Involvement of five or more contiguous thoracic vertebral segments has been reported only three times previously in the literature [
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The authors declare that there is no conflict of interests regarding the publication of this paper.