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CASE REPORT Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 1  |  Page : 64-65
Insufficiency fracture of the spinous process of C7 vertebra - A case report

1 Indira Gandhi Medical College and Mayo General Hospital, Nagpur, India
2 Sushrut Hospital, Research Centre and PostGraduate Institute of Orthopaedics Ramdaspeth, Nagpur, India

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How to cite this article:
Pande KC, Tripathi S. Insufficiency fracture of the spinous process of C7 vertebra - A case report. Indian J Orthop 2005;39:64-5

How to cite this URL:
Pande KC, Tripathi S. Insufficiency fracture of the spinous process of C7 vertebra - A case report. Indian J Orthop [serial online] 2005 [cited 2019 Jul 22];39:64-5. Available from:

   Introduction Top

Insufficiency fracture occurs when normal or physiologic muscular activity stresses a bone that is deficient in mineral or elastic resistance. It is known to occur in a wide variety of conditions [1],[2],[3] .

We report a case of insufficiency fracture of the spinous process of C 7 . Diagnosis of osteomalacia was made on the basis of biochemical changes and osteopaenia confirmed by Bone Mineral Density (BMD) assessment.

   Case Report Top

A 29-year-old lady presented with acute onset pain at the cervico-thoracic junction. The patient was 6 months post­partum and involved in lifting her baby. There was no history of prior trauma or systemic illness. The pain was localized and made worse by movements of neck and arms. On physical examination, there was severe local tenderness over the spinous process of C 7 and the overlying skin was non­erythematous. Attempted movements of the cervical spine were painful and there was no neurological deficit.

Routine radiography demonstrated a linear fracture of the spinous process of C 7 with distraction [Figure - 1]. MRI of the spine (1.5 T, Siemens 63 SP, Erlangen Germany) confirmed the fracture. It was seen as a linear zone of low signal intensity surrounded by a broader, poorly defined area of higher signal intensity on T 2 -weighted sagittal images. The changes were similar but less marked on the sagittal T 1 -weighted images [Figure - 2]a,b. There was no evidence of any local pathology. Routine haematology was normal. Serum biochemistry revealed a low serum calcium (1.71 mmol/l; reference range 2.2-2.6 mmol/l) and elevated serum alkaline phosphatase (ALP) (441 IU/l; reference range 60-306 IU/l), confirming the diagnosis of osteomalacia. Bone Mineral Density at the spine was found to be 77% (T score -2.20) and at the hip it was 73% (T score -2.05), of young adult mean.

The patient was treated by cervical spine immobilization using soft collar and the metabolic abnormality corrected by administration of calcium and vitamin D supplements. Patient was asymptomatic 3 months after treatment and the serum biochemistry was normal (Serum Calcium 2.54 mmol/l and serum ALP 285 IU/l)

   Discussion Top

Insufficiency fractures are most often seen in elderly females who have postmenopausal osteoporosis [1],[3]. In a study of 60 patients with insufficiency fracture seen over a period of 8 years, Soubrier et al [3] found osteoporosis to be the underlying cause in 50% of cases.

Insufficiency fractures have also been reported in patients after radiation therapy, metastatic disease, and osteoporosis secondary to corticosteroid use and in patients with rheumatoid arthritis. The other causes of insufficiency fracture include diabetes mellitus, Paget's disease, osteomalaia or rickets, hyperparathyroidism, renal osteodystrophy, osteogenesis imperfecta, osteopetrosis, and fibrous dysplasia [1],[2],[3],[4] .The most commonly reported sites for the occurrence of insufficiency fractures are sacrum, ilium, pubis, and long bones of the upper and lower extremity [1],[3] . We are not aware of any report of insufficiency fracture of the cervical spinous process.

Isolated cervical spinous process fracture is referred to as 'clay shoveler's fracture'. The most common cause of this fracture is muscular and ligamentous stresses induced by strenuous use of the arms and shoulders. It may also result from hyperflexion injury of the cervical spine [5] .

The primary radiographic finding in stress fractures of the cancellous bone is sclerosis from trabecular compression and callus formation [6] . In this case no sclerosis was evident as there was separation of the fracture fragments rather than compression. They may be difficult to detect, especially in the presence of osteoporosis [7]. Bone scintigraphy is the procedure of choice [3] but MR imaging in patients with stress fracture has been describeed with comparable sensitivity and superior specificity to bone scintigraphy [8],[9] .

Stress fractures appear most typically as a linear zone of low signal intensity surrounded by a broader, poorly defined area of higher signal intensity on T 1 -weighted spin scho MR images [9] . The findings represent the edema in the marrow or in the soft tissues surrounding the fracture [8],[10] . The MRI findings in the case are consistent with those described in the literature.

In the case reported, acute onset of pain in the absence of trauma raised a suspicion of an insufficiency fracture. Investigations were done to rule out any coexistent local pathology. Plain radiographs and MRI revealed insufficiency fracture and ruled out any focal lesion. Osteopaenia secondary to osteomalacia was confirmed on BMD assessment and biochemical testing.

In summary, a case of insufficiency fracture of spinous process of cervical vertebra is reported. A possibility of coexistent metabolic bone disease should be investigated in patients with unusual insufficiency fractures.

   References Top

1.Resnick D, Niwayama G. Diagnosis of bone and joint disorders. Ed.3. Philadelphia; WB Saunders, 1995.  Back to cited text no. 1    
2. Daffner RH, Pavlov H. Stress fractures; Current Concepts. Am J Rheumatol. 1992;150:245-252.  Back to cited text no. 2    
3. Soubrier M, Dubost JJ, Boisgard S, Sauvezie B, Gaillard P, Michel JL, Ristori JM. Insufficiency fracture. A survey of 60 cases and review of literature. Joint Bone Spine. 2003;70:209-218.  Back to cited text no. 3    
4. Pentecoast Rl, Murray RA, Brindley HH. Fatigue, insufficiency and pathologic fractures. J Am Med Assoc 1964;187:1001-1004.  Back to cited text no. 4    
5. Hirsh LF, Duarte LE, Wolfson EH, Gerhard W. Isolated symptom­atic cervical spinous process fracture requiring surgery: Case report. J Neurosurg, 1991;75:131-133.  Back to cited text no. 5    
6. Savaco CJ. Stress fractures: a classification of the earliest radiographic signs. Radiology. 1971;100:519-524.  Back to cited text no. 6    
7. Manco LG, Schneider R, Pavlov H. Insufficiency fractures of the tibial plateau. AJR 1983;140:1211-1215.  Back to cited text no. 7    
8.Lee JK, Yao L. Stress fractures: MR Imaging. Radiology.1988;169:217­220.  Back to cited text no. 8    
9. Deutsch AL, Mink JH. Magnetic resonance imaging of musculoskel­etal injuries. Radiol Clin North Am.1989;27:983-1002.  Back to cited text no. 9    
10. Stafford SA, Rosenthal DI, Gebhardt MC, Brady TJ, Scott JA. MRI in stress fracture. Am J Rheumatol. 1986;147:553-556.  Back to cited text no. 10    

Correspondence Address:
Ketan C Pande
Centre for Osteoporosis Management & Research, Sushrut Hospital, Research Centre and Post Graduate Institute of Orthopaedics, Ramdaspeth, Nagpur,
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Source of Support: None, Conflict of Interest: None

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