Fractures of the process of the lower spine or upper thoracic spine are often referred to as clay-shoveler’s fractures.
Initially reported in 1940, these fractures were described among employees in Australia who dug drains in clay soil and also threw the clay overhead with shovels. The mud wouldn’t discharge from the spade, causing excess power to be transmitted into the supraspinous ligaments and leading to an avulsion fracture of one or more spinous processes.
The following frequently describes the mechanism of injury for clay shoveler’s fractures. The contraction of the paraspinal and trapezius muscles on the ligaments along with the attachment to the spinous processes make this a common injury during athletics with a flexed position of the shoulders and neck. The consequent fracture or apophyseal avulsion is painful and frequently requires a visit to the doctor, together with plain films, computed tomography (CT) scans, or magnetic resonance imaging (MRI) confirming the identification.
Often a period of rest will allow a return to activity, although treatment of these fractures hasn’t been clarified. We present a collection of adolescent athletes who underwent surgical interventions to treat the fracture of the spinous process, after rest and physical therapy with persistent symptoms.
Dr. Hedequist operated on 3 patients using a spinous process nonunion within the study time period. The patients’ average age was 14 years; the location of the spinous process fracture was the T1 vertebra in all patients. Two patients sustained the injury while playing hockey and one while wrestling. The average duration of symptoms before surgery was 10 months; all patients had seen physicians without a diagnosis before test in institution. All patients had a trial of physical therapy and all had been unable to return after trauma to pain.
Examination of patients showed pain directly over the fracture site and accentuated by forward flexion of the neck and neck. Evaluation of harm plain films revealed a fracture fragment in two patients (Figure 1). All 3 patients underwent CT and MRI scans confirming the identification. MRI confirmed areas of increased signal at the tip of the T1 spinous process, with inflammation in the supraspinous ligament directly at that area (Figure 2). The CT scans confirmed the presence of a bony fragment correlating with the suggestion of the T1 spinous process (Figure 3).
Surgery was performed under general endotracheal anesthesia using a midline incision over the affected region down to the spinous procedure. The supraspinous ligament was opened showing an identified and ununited ossicle, which has been removed without taking down the ligament. All 3 nonunions have been noted to be atrophic with no evidence of surrounding inflammatory tissue or bursa. The residual end of the spinous process was smoothed down with a rongeur. Standard closure was performed. There were no surgical complications.
All patients had complete relief of pain at followup; 1 individual returned to full sports activity at 6 months and the other 2 returned to full sports activity at 3 months. There was no loss of peripheral movement or trapezial strength at follow-up. All patients expressed satisfaction together with the decision.
Clinical practice suggests that most patients with spinous process fractures will become pain-free; however, that is not universal. This series demonstrates that a tiny subset of patients with this trauma will continue to have significant symptoms despite a period of rest. In those patients who want a yield to sports, we recommend consideration of surgical excision after confirmation of nonunion with studies. The inherent risks of surgical treatment are minimal with this procedure, and the advantages include return for athletes, with the physical and psychosocial benefits to pain-free sports activity.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
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