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 .