The vast majority of patients presenting with a concussion do not require any imaging – and do not have any structural abnormalities. However, it is essential that you consider whether there has been an associated cervical spine injury.
This image shows a fracture of the C7 spinous process. This injury occurred following a flexion-extension injury during a rugby tackle. In addition to concussive symptoms, this patient also complained of significant neck pain and a loss of movement.
This type of injury generally occurs after sudden flexion of the head. It can also occur after repeated stress caused by the pulling of the trapezius and rhomboid muscles on the spinous processes. This injury is colloquially known as a “clay shovelers fracture” as it was a relatively common occurrence in clay miners in Australia during the 1930s. These labourers dug deep ditches and were required to toss clay 4-5 meters above their heads with long-handled shovels. Instead of having the clay come cleanly off the shovel, it would sometimes stick. When this happened there would be a sudden contraction of the trapezius and rhomboid muscles in response to the sudden surge of shear forces from the weighted shovel. This would cause an acute avulsion fracture. The lower cervical or upper thoracic spinous processes are general affected as they have longer and more vulnerable spinous processes.
This type of injury is generally best seen on a lateral x-ray image. It is usually a very stable fracture and does not produce any neurologic deficits. It typically heals with 6-8 weeks of relative rest with no further treatment being needed in most cases.