Fracture, Spinous and Transverse Processes

By admin On Sep 20, 2023

Ovid: 5-Minute Sports Medicine Consult, The

David E. J. Bazzo

Tara Robbins

Basics

Description

Transverse and spinous process fractures are considered minor spine injuries and usually are stable and benign. Both types can be markers of considerable trauma and should encourage the physician to look for additional injury.
Fractures of the spinous process typically occur at C7 or any of the lower cervical or upper thoracic vertebrae. They are commonly avulsion-type injuries resulting from contraction of the trapezius, rhomboid minor, and/or serratus posterior.
Traditionally referred to as “clay shoveler injuries,” but now are found mostly after sudden deceleration in motor vehicle accidents or forced flexion of the neck, often in football players and weightlifters
Synonym(s): Minor spinal fracture

Epidemiology

Spinous process fractures are relatively rare since mechanization replaced clay shovelers.
“Sentinel spinous process fractures” are associated with fractures of lamina and facets, which can lead to instability.
Up to 21% of transverse process fractures resulting from high-energy trauma (eg, motor vehicle accidents) are associated with visceral injuries, most commonly to the spleen and liver (1).
Up to 11% have other spine injuries not detected by plain radiographs but identified on CT scanning (1).
Transverse process fractures resulting from low-energy trauma (eg, playing football) do not generally have associated spinal, nerve root, or visceral injuries.

Risk Factors

Growth spurts, training errors, improper technique, and repetitive trauma predispose the athlete to spine fractures.

Diagnosis

History

Forceful hyperflexion of the neck (eg, spearing in football) is associated with lower cervical spinous process fractures. Lumbar transverse process fractures usually result from direct trauma.
Pain with hip flexion indicates possible lumbar transverse process fracture. Pain with neck flexion suggests cervical spinous process fracture.

Physical Exam

Localized pain over injured area without radiation
Pain increased with neck flexion (lower cervical spinous process fracture) or hip flexion (lumbar transverse process fracture)
Careful neurologic examination for weakness, reflex changes, or sensory changes in a dermatomal distribution. As neurologic injuries are not commonly associated with minor fractures, abnormal results should raise suspicion of additional spinal injury.
Pain worse with hip flexion (site of iliopsoas origin) seen in lumbar transverse process fractures
Benign abdominal examination does not exclude coexistent intra-abdominal injury.

Diagnostic Tests & Interpretation

Imaging

CT scan: Superior to plain films to evaluate extent of spinal fractures and rule out serious spine injury, but has limited field of view and high radiation dose
MRI: Only necessary if neurologic symptoms are present to evaluate extrinsic spinal cord compression or intrinsic cord injury
Radiographic appearance often lags behind clinical healing and should not be used as the primary criterion for return to play.
Cervical lateral radiograph:
- Very important to visualize C7 spinous process, which often is obscured by the shoulders
- Obtain “swimmer's view” if necessary to visualize C7–T1 junction.
- Anteroposterior (AP) radiograph may show double shadow of spinous process due to avulsion.
- Flexion-extension films to rule out ligamentous instability and lamina or facet injury
Thoracolumbar AP radiograph:
- Relatively insensitive at identifying transverse process fractures
- May show double shadow of spinous process due to avulsion
- Hematoma may obscure evidence of transverse process fracture. Loss of normal psoas shadow may be most prominent finding.
- Oblique radiograph to rule out defects in pars interarticularis

Differential Diagnosis

“Burst” fracture
Lumbar strain
Disc herniation
Spondylolysis and/or spondylolisthesis

Treatment

Rest is often the most effective treatment for isolated injury.
Cryotherapy repeated frequently within initial 36–48 hr may help prevent muscle spasm.
NSAIDs and gentle exercises may be helpful.
In all cases of suspected spine injury, immobilization with a backboard and rigid cervical collar is mandatory until the patient can be cleared radiographically.

P.253

Additional Treatment

Additional Therapies

If transverse process fractures result from high-energy trauma, there should be a high index of suspicion for associated visceral injuries. Urinalysis should be performed; if >8 RBCs per high-power field are seen, perform cystogram and IV pyelogram to evaluate for possible urinary tract injury (1).
If transverse process fractures are identified on plain radiographs, abdominal CT should be performed due to possible associated visceral and abdominal injuries (1).
With cervical injury, protection against flexion with an orthosis should be provided for 4–6 wks:
- Obtain flexion/extension radiographs at end of immobilization period.
- Return to play once fracture is healed and patient has full, painless range of motion and no neurological deficits (2)[B].
There is controversy whether bracing is beneficial in thoracolumbar fractures without associated spinal injury. Some authors have suggested the use of bracing for symptomatic relief. Others have shown that it is not effective in immobilization and can result in complications such as skin breakdown. At the time of publication, there is no evidence for the effectiveness of bracing in patients with thoracolumbar fractures (3,4)[B].
If there is associated spinal injury, a rigid orthosis is needed. The patient should be limited to isometric exercises, with restricted upper extremity exercises, until full range of motion and no tenderness to palpation are present.
Isolated fractures of the transverse process usually cause disability for a few weeks and carry a very low likelihood of long-term sequelae. Early mobilization and physical therapy is important in rehabilitation:
- Healing of the transverse process often does not occur because of distraction of the fracture fragment from muscle pull. Healing is often determined by radiographs and palpation at site of injury.
- Return to play once range of motion is painless and the trunk has been strengthened.
- Likely no equipment changes will be needed in noncontact sports, but padded equipment modification may be helpful in reducing the risk for reinjury in contact sports.
Contiguous transverse process fractures should be observed carefully for development of pseudoarthrosis or myositis ossificans.

Surgery/Other Procedures

Nonunion of fractured fragments is common in both injuries, but most authors advocate avoiding excision of fragments unless pain persists beyond the period of immobilization.

Ongoing Care

Follow-Up Recommendations

Patients with isolated fractures do not need orthopedic or neurosurgical referral.

References

1. Patten RM, Gunberg SR, Brandenburger DK. Frequency and importance of transverse process fractures in the lumbar vertebrae at helical abdominal CT in patients with trauma. Radiology. 2000;215:831–834.

2. Boden BP, Jarvis CG. Spinal injuries in sports. Neurol Clin. 2008;26:63–78.

3. Giele BM, Wiertsema SH, Beelen A, et al. No evidence for the effectiveness of bracing in patients with thoracolumbar fractures. Acta Orthop. 2009;80:226–232.

4. Homnick A, Lavery R, Nicastro O, et al. Isolated thoracolumbar transverse process fractures: call physical therapy, not spine. J Trauma. 2007;63:1292–1295.

5. Tewes DP, Fischer DA, Quick DC, et al. Lumbar transverse process fractures in professional football players. Am J Sports Med. 1995;23:507–509.

Additional Reading

Krueger M, Green D, Hoyt D, et al. Overlooked spine injuries associated with lumbar transverse process fractures. Clin Orthop Rel Research. 1996;327:191–195.

Nicholas J, Nuber G, eds. The lower extremity and spine in sports medicine. St. Louis: Mosby, 1995.

Sturm JT, Perry JF. Injuries associated with fractures of the transverse processes of the thoracic and lumbar vertebrae. J Trauma. 1984;24:597–599.

Codes

ICD9

805.00 Closed fracture of cervical vertebra, unspecified level
805.2 Closed fracture of dorsal (thoracic) vertebra without mention of spinal cord injury

Clinical Pearls

The average time lost from sports reported in a National Football League study was 25 days for lumbar transverse process fractures, but varies from case to case, depending on the number of vertebral levels involved and any associated injury (5).
Athletes involved in contact sports may feel more comfortable in a flak jacket, although there is no evidence that they prevent reinjury or accelerate return to competition.
Most common occurrence is at the levels of C7>C6>T1
Forced hyperflexion is the usual mechanism of injury.