A Pain in the Neck

A physician for a multiple-stage trail race in the Nepal Himalayas was called to the scene of an accident that had happened approximately 100 m from the start of one of the stages in a remote settlement at 3400 m. From the starting line, the runners had crossed the courtyard of a monastery before funneling through a small doorway in the wall. When the physician reached the scene, he found a 41-year-old male runner with a head injury. The runner had been sprinting to get to the front of the pack when he hit his head on the top of the doorway (Figure 1). The patient was conscious and sitting upright. He had a laceration of his forehead that was bleeding. The patient was trying to stop the bleeding and was being helped by other runners. He denied loss of consciousness. He complained of widespread paresthesias of his extremities. While the physician was assessing the patient, the paresthesias decreased until they were limited to the proximal hands. The physician noted minimal diffuse tenderness over the region of the sixth and seventh cervical spinous processes. Neurology examination was normal except for the remaining paresthesias over the thumb and the web space between the thumb and index fingers bilaterally.

Figure 1

The patient and the doorway. Photo courtesy of Richard Bull.

What is the diagnosis? How would you manage this patient?

Diagnosis

Clay shoveler’s fracture due to cervical spine trauma.

Management of The Case

While the physician was suturing the laceration, the patient’s paresthesias improved markedly until they almost resolved. The patient (one of the authors, S.W.) declined medical evacuation. The physician and the patient decided that the patient should continue cautiously without any special measures to stabilize the cervical spine, but carrying no weight, with the physician beside him at all times. If the symptoms worsened, the patient would be evacuated promptly. The patient continued in this way for the rest of the day. That evening, they sought advice from other runner physicians on the team. Because there was no progression of symptoms, physician and patient decided to continue on, with caution.

The physician carefully observed the patient during the 7 remaining days of the trip for any worsening of symptoms. During this time, the team, including the patient, covered more than 100 km by foot, crossing a pass more than 5000 m high. The patient reached the end of the trek without further complications. On return to Kathmandu, a radiograph of the cervical spine was obtained and showed fractures of the spinous processes of C-6 and C-7 (Figure 2). This stable injury was managed conservatively without further intervention. One year later, the patient continues to run trails and has only a trace of paresthesia in the left hand, between the index finger and the thumb.

Figure 2

Lateral cervical X-ray film showing posterior avulsion fractures of the spinous processes of C-6 and C-7.

Discussion

Isolated fractures of the lower cervical spinous processes are often referred to as “clay shoveler’s fractures.” Typically, these are avulsion fractures. They commonly occur in football players and power lifters, usually at C-7. ¹ Clay shoveler’s fractures are generally due to forceful flexion of the cervical spine or forceful contraction of the trapezius and rhomboid muscles. Other mechanisms, including hyperextension, as in this case, and rotation of the neck have been described. These fractures are stable and can usually be treated with conservative measures.

Although some guidelines for selective stabilization of the cervical spine after trauma include the mechanism of injury as a predictor of spinal fracture,^2,3 accidents that are apparently benign, such as knocking one’s head on a low door, can also cause fractures, as in the current case. Most doorways in rural Nepal are low. There are many accounts of trekkers hitting their heads on them, but as far as we know, there are no previous reports of spinal fractures due to this mechanism. There are numerous anecdotal reports of trail runners hitting their heads on overhanging tree branches, particularly when focused on the terrain or on speed and when foreground vision was obscured with hats that have long bills, as was the case in this situation.

When a neck injury occurs in a remote setting, the decision whether to stabilize the cervical spine can affect not only the victim, but also the safety of the rescuers. The patient in this case did not have significant spinal pain or tenderness and was able to voluntarily flex, extend, and rotate 30 degrees in all planes. According to the Wilderness Medical Society Practice Guidelines for Spine Immobilization in the Austere Environment, ³ spinal stabilization was not indicated.