clay - shoveler 's fracture is isolated spinous process avulsion fracture classically observed in the lower cervical or upper thoracic spine .
this type of fracture is most common in those who engaged in hard physical labor3,6,7 ) .
recently , several cases of isolated spinous process fractures that are caused by motor vehicle accidents or sports injuries have been reported ( table 1 ) .
isolated spinous process fractures are most common at the level of t1 , followed by c7 , t2 , t3 , and c61,7 ) . among them , multiple spinous process fractures are very rare1 ) .
we present a case of multiple isolated spinous process fractures with twelve contiguous levels of the cervico - thoracic spine , which extended from c4 to t8 . to the best of our knowledge ,
this case is the most multiple spinous process fractures so far reported in the literatures .
a 34-year - old man was transferred our hospital from local clinic after motorcycle accident .
initial spine x - rays showed multiple spinous process fractures in the cervico - thoracic spine . computed tomography
( ct ) scanning of the cervicothoracic spine showed twelve contiguous spinous process fractures ranged from c4 to t8 ( fig .
cervico - thoracic spine magnetic resonance images ( mri ) revealed that spinal cord was normal and there was no additional soft tissue injury ( fig .
after 3 months , we evaluated follow - up cervico - thoracic ct scanning which did n't show union of spinous process fractures yet .
after 6 months follow - up , visual analogue scale score was gradually improved from 6 to 1 .
clay - shoveler 's fracture may occur through direct trauma on the flexed spine or through shear forces2,3,4,5,6,7 ) .
muscle and ligamentous stress is transmitted through the supra - spinous ligaments and results in an avulsion fracture of the spinous processes2 ) .
our case is an unusual example for multiple spinous process fracture that can be produced by several mechanisms , such as a direct blow to the posterior aspect of lower neck and the thorax , upper back hyperextension , and hyperflexion injuries against the supraspinous ligament after motorcycle crash .
a double spinous process sign at the affected level can be detected on simple antero - posterior radiographs6,9 ) .
downward displacement of fractured spinous process fragments ( spinolaminar breach sign ) can be seen on lateral radiograph views3,6,7 ) .
isolated spinous process fracture considered as a warning sign for more severe spinal injury , so it should be evaluated carefully to detect more severe spinal injuries7 ) .
ct and mri of the cervical and thoracic spine may be useful for detecting more serious spine fractures and further injuries to surrounding structures including spinal cord and ligament3,6 ) .
generally , this type of fractures are treated conservatively without the need for surgical intervention3,5,8 ) .
immobilization and restriction of physical activity for 4 to 6 weeks generally result in good outcome3,8 ) .
our patient shows good clinical outcome after 4 weeks immobilization and restriction of physical activity .
we report a case of twelve isolated spinous process fracture of the cervico - thoracic spine after motorcycle accident .
 the clay - shoveler 's fracture is an isolated avulsion fracture of the lower cervical or upper thoracic spinous process . among them , multiple spinous process fractures are very rare . 
 we present 34-year - old male patient who have multiple spinous process fractures with twelve contiguous levels of cervico - thoracic spine ( from c4 to t8 ) after motorcycle accident . 
 this case is multiple isolated spinous process fractures with good clinical outcome . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION