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 » Introduction
 » Case Report
 » Discussion
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Table of Contents    
CASE REPORT
Year : 2015  |  Volume : 63  |  Issue : 2  |  Page : 223-224

Six-level isolated spinous process fracture of the thoracic vertebrae (clay-shoveler's fracture) and a review of the literature


Department of Neurosurgery, Ataturk Education and Research Hospital, Ankara, Turkey

Date of Web Publication5-May-2015

Correspondence Address:
Dr. Atilla Kazanci
Department of Neurosurgery, Ataturk Education and Research Hospital, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.156286

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 » Abstract 

Clay-shoveler's fractures are isolated, avulsion-type spinous process fractures of the lower cervical and upper thoracic vertebrae. Multi-level fractures of the spinous processes are extremely rare. We report the case of a 60-year-old female patient with a six-level isolated spinous process fracture of the thoracic spine. Our case is the fourth reported case in literature, of an isolated spinous process fracture involving five or more levels in the thoracic vertebrae.


Keywords: Clay shoveler′s fracture; multiple fractures; thoracic and cervical spine fractures


How to cite this article:
Kazanci A, Gurcan O, Gurcay AG, Turkoglu OF, Bavbek M. Six-level isolated spinous process fracture of the thoracic vertebrae (clay-shoveler's fracture) and a review of the literature. Neurol India 2015;63:223-4

How to cite this URL:
Kazanci A, Gurcan O, Gurcay AG, Turkoglu OF, Bavbek M. Six-level isolated spinous process fracture of the thoracic vertebrae (clay-shoveler's fracture) and a review of the literature. Neurol India [serial online] 2015 [cited 2019 Oct 23];63:223-4. Available from: http://www.neurologyindia.com/text.asp?2015/63/2/223/156286



 » Introduction Top


Clay-shoveler's fractures are isolated, avulsion-type, spinous process fractures of the lower cervical and upper thoracic vertebrae, originally described in clay shovelers from Australia. [1] Hyperflexion and rotation of the spine as well as direct and/or indirect trauma may cause these fractures. X-rays and computed tomographic scans are the gold standards of investigation for the diagnosis of clay shoveler's fractures. The major complaint of patients having an isolated spinous process fracture is local pain that is usually resolved with a conservative approach. [2],[3],[4],[5] Multi-level spinous process fractures are extremely rare in literature. [2],[3],[5],[6],[7],[8],[9] We report a six-level isolated spinous process fracture of the thoracic spine. To the best of our knowledge, this is the fourth case of isolated spinous process fracture involving five or more thoracic vertebral levels.


 » Case Report Top


A 60-year-old female patient was admitted to our hospital with a complaint of pain in the thoracic region that developed after an automobile accident. Her physical examination revealed tenderness in the thoracic spine. She had no neurological deficits. Radiographs of the thoracic spine and computed tomographic scans demonstrated isolated spinous process fractures of T4-T9 vertebrae without evidence of additional vertebral body lesions [Figure 1]a-c. The patient was treated conservatively with analgesics and oral muscle relaxant medication. Immobilization was maintained by a thoracolumbar hyperextension (Jewett type) brace for 6 weeks. Relief in pain was achieved gradually. The 3-month follow-up of the patient showed a good clinical outcome without neurological deficits. The computed tomographic scan revealed partial fusion of the spinous process fractures at a follow-up of 3 months [Figure 2].
Figure 1: (a) Sagittal thoracic computed tomographic scan showing a six level (T4-T9) isolated spinous process fracture (b) Axial thoracic computed tomographic scan showing an isolated spinous process fracture at T5 level. (c) Axial thoracic computed tomographic scan showing an isolated spinous process fracture at T8 level

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Figure 2: Sagittal thoracic computed tomographic scan showing partial fusion of the six level (T4-T9) isolated spinous process fracture after a 3-month follow-up

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 » Discussion Top


Clay-shoveler's fractures are stable, isolated spinous process fractures of the lower cervical and upper thoracic vertebrae classically seen at the C6 or C7 level. [2],[4],[5],[8],[9],[10],[11],[12] They occur secondary to stress forces exerted by muscles and ligaments that are transmitted through the supraspinous ligaments. [3],[4],[6],[8],[9] Isolated spinous process fractures are mostly described at one level. Multi-level isolated spinous process fractures are extremely rare. A review of literature is given in [Table 1]. Our case is the fourth case reported in literature, of an isolated spinous process fracture involving five or more levels in the thoracic vertebrae.
Table 1: Summary of multiple isolated spinous process fractures


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The clinical presentation consists mainly of tenderness and pain in the lower cervical and upper thoracic spine. This is usually without any neurological deficit. [2],[3],[4],[5],[7],[10] If the fracture extends into the vertebral body, pedicle or lamina, concomitant spinal cord compression or instability may be detected. The fracture may characteristically be indicative of thorax, kidney or liver trauma ıf the mode of injury is severe such as sustained in an automobile or a climbing accident. Patients with multi-level thoracic clay-shoveler's fractures must be evaluated with a high index of suspicion for a coexisting pneumothorax or hemothorax. The treatment of isolated spinous process fractures is conservative aided by analgesics and spinal immobilizing braces. [2],[3],[4],[5],[6],[9],[10],[11],[12] Thoracolumbar braces that maintain hyperextension of the spine are recommended for multi-level clay-shoveler's fractures of the thoracic spine. Only a longstanding persistence of pain may be a relative indication for surgery carried out for isolated clay-shoveler's fractures. If the fracture extends into the vertebral body, pedicle or laminar regions, spinal instability, or nerve root or spinal cord compression must be looked for. The total duration of treatment of these patients with analgesics, muscle relaxant medication and a thoracolumbar brace is approximately for 6 weeks. In the available literature, the majority of patients treated conservatively show a good clinical outcome, as was seen in our patient.

 
 » References Top

1.
Hall RD. Clay-Shoveler's fracture. J Bone Joint Surg Am 1940;22:36-75.  Back to cited text no. 1
    
2.
Kose KC. Case report: The impact of pseudoarthrosis on clinical outcome in isolated spinous process fractures of six adjacent level thoracic vertebrae. Med Gen Med 2006;8:67.  Back to cited text no. 2
    
3.
Akhaddar A, El-asri A, Boucetta M. Multiple isolated thoracic spinous process fractures (Clay-Shoveler's fracture). Spine J 2011;11:458-9.  Back to cited text no. 3
    
4.
Yamaguchi KT Jr, Myung KS, Alonso MA, Skaggs DL. Clay-shoveler's fracture equivalent in children. Spine (Phila Pa 1976) 2012;37:E1672-5.  Back to cited text no. 4
    
5.
Kang DH, Lee SH. Multiple spinous process fractures of the thoracic vertebrae (Clay-Shoveler's Fracture) in a beginning golfer: A case report. Spine (Phila Pa 1976) 2009;34:E534-7.  Back to cited text no. 5
    
6.
Kim SY, Chung SK, Kim DY. Multiple cervical spinous process fractures in a novice golf player. J Korean Neurosurg Soc 2012;52:570-3.  Back to cited text no. 6
    
7.
Solaroglu I, Kaptanoglu E, Okutan O, Beskonakli E. Multiple isolated spinous process fracture (Clay-shoveler's fracture) of cervical spine: A case report. Ulus Travma Acil Cerrahi Derg 2007;13:162-4.  Back to cited text no. 7
    
8.
Umredkar A, Sura S, Mohindra S. Multiple contiguous isolated spinous process fracture (Clay-Shoveler's fracture) of the cervicodorsal spine. Neurol India 2011;59:788-9.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.
Han SR, Sohn MJ. Twelve contiguous spinous process fracture of cervico-thoracic spine. Korean J Spine 2014;11:212-3.  Back to cited text no. 9
    
10.
Kaloostian PE, Kim JE, Calabresi PA, Bydon A, Witham T. Clay-shoveler's fracture during indoor rock climbing. Orthopedics 2013;36:e381-3.  Back to cited text no. 10
    
11.
Unay K, Karatoprak O, Sener N, Ozkan K. A clay-shoveler's fracture with renal transplantation and osteoporosis: A case report. J Med Case Rep 2008;2:187.  Back to cited text no. 11
    
12.
Matz SR, Reeder JD. Spinous process fractures in a jockey: A case report. Am J Orthop (Belle Mead NJ) 1999;28:365-6.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]

This article has been cited by
1 Clay-shoveler’s fracture: A snapshot
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[Pubmed] | [DOI]
2 Multiple Adjacent Isolated Thoracic Spinous Process Fractures in High-Energy Trauma
Jacob M. Kirsch,Amit Nathani,Rakesh D. Patel
Case Reports in Orthopedics. 2015; 2015: 1
[Pubmed] | [DOI]



 

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