A 28-year-old recreational player presents with a longstanding history of neck pain. She describes injuring it during a match four years previously. She is unable to recall the exact mechanism but remembers developing acute neck pain that prevented her playing for more than one month. Since this time she describes having experiences relatively constant low-level discomfort in her neck that was made worse by sitting for long periods and by playing football. On examination she had a normal cervical range of motion and no focal neurology. The only finding of note was of localised tenderness over the lower cervical spine in the midline.
A lateral x-ray of the cervical spine shows an undisplaced fracture of the C7 spinous process. The fracture margins are wide and sclerotic suggesting that is it longstanding. The SPECT shows prominent increased uptake at the C7 spinous process in the region of the fracture. Finally, a sagittal MRI sequence further demonstrates a fracture of the spinous process of C7 with the fractured surfaces appearing corticated (indicating an established non-union).
While the history and x-ray findings suggested that the fracture was longstanding the florid increased, the increased uptake seen on the SPECT scan (when combined with the ongoing localised pain and tenderness) suggested that the fracture was the cause of her ongoing symptoms. After a literature search and discussion about the available treatment options this player opted to have the unstable fracture fragment surgically excised. Following surgery there was a significant improvement in her symptoms. Her pain resolved over a four-month period and she was able to return to normal activities.
The majority of fractures involving the spinous processes occur in the lower cervical or upper thoracic spine. They most commonly affect the C7 vertebrae, but have been reported to occur at any level between C6 and T3. In some cases the fracture can occur due to direct trauma however they are generally avulsion injuries resulting from sudden muscular or ligamentous pull. In the majority of cases the fracture occurs in isolation and can be considered to be a stable injury. It is however important to consider the possibility of other associated injuries including a lamina fracture or facet dislocation. In the vast majority of cases these injuries settle with time and avoidance of pain provoking activities. Analgesics, a cervical collar and physiotherapy techniques can all help provide symptomatic relief. Surgical treatment is rarely needed.
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