Isolated Spinous Process Fracture: A Commonly Missed Diagnosis

Spinous process fractures of the cervical spine are generally considered stable injuries, particularly when they resemble the classic clay-shoveler's fracture, which typically results from indirect traction forces. However, in certain traumatic settings, these fractures may serve as markers of underlying spinal instability. We report the case of a 93-year-old woman who sustained a fall following a syncopal episode, striking her head on furniture. On initial evaluation, she was neurologically intact, and computed tomography (CT) of the head and cervical spine revealed no clear fracture or dislocation. Within 24 hours, she developed progressive quadriparesis. Repeat CT demonstrated a subtle C6 spinous process fracture with posterior facet joint subluxation and anterior displacement of C5 on C6. Magnetic resonance imaging (MRI) revealed a C5-C6 fracture-dislocation with marked anterolisthesis and significant ligamentous injury. The patient underwent spinal traction followed by anterior cervical discectomy, fusion, and plating, resulting in substantial neurological improvement. This case highlights that even subtle spinous process fractures may indicate serious underlying injury. Unlike isolated clay-shoveler's fractures, trauma-associated spinous process fractures should prompt further evaluation, particularly with MRI, in patients presenting with delayed or evolving neurological deficits. Early recognition of ligamentous instability is essential to prevent secondary deterioration and optimize clinical outcomes.