Question
I apologize ahead of time for how long this is, but I want to be as thorough as I can about my entire situation.  On 03/06/2008 I fractured my C2 odontoid doing a backflip on a trampoline at a gymnastics class.  I landed on the back of my neck from about 6 or 7 feet high and the force sort of smashed my chin into my chest as I rolled over backwards.  I'm a 21 (20 at the time) year old male, and before the accident, I'd describe myself as extremely healthy and active.  A neurosurgeon at the hospital recommended a C2 ondontoid screw placement, and I had that surgery four days after the accident.  I couldn't swallow for several days after the surgery, and continued to have a lot of difficulty even after the swelling went down.

About two weeks later at my follow-up appointment, x-rays revealed that the screw was not holding correctly (the odontoid had like slipped forward out of the screw or something), so I had another surgery to remove the screw and place me in a halo.  My doctor had a lot of trouble getting the odontoid aligned, and he told me that it was about "50% on" (too far forward) and that it was the best he could do.  He was a little worried about fusion with the misalignment, but said at my age chances were still pretty good.  I also developed some numbness in my right shoulder, but the vest seemed to be loose enough, he said, so it was attributed to my accident (which didn't make sense to me since it didn't appear until the day after I got my halo on).  As time went on, I ended up having a lot of pain in that shoulder, especially closer to the base of my neck.  Lying down or sitting in a certain way would alleviate the pain.  Another problem that came up was that I had totally lost my ability to swallow after this second surgery.  I was looked at by my neurosurgeon, a speech therapist, and an ENT, and the best they could speculate was that there might have been some nerve damage during the surgeries to my throat, but that it would likely regenerate.

After a week of not eating, I got a dobhoff tube, which I fed through for the next three weeks, after which I had surgery to have a PEG tube placed.  Shortly thereafter, I had a fairly impressive infection, which required yet another surgery to treat.  I again went another week without "eating" anything.  At this point, I had lost about 30 pounds (I dropped to 110 pounds at one point and I'm not exactly a tiny person at 5'11").  With all these complications (especially the lack of nourishment) coupled with the initial 3 month prediction for wearing the halo, I was very surprised when just 6 weeks after getting my halo on, my doctor told me a CT scan showed that the bone had already fused enough to take the halo off.  I was so shocked I didn't think to ask any questions, and I went home not knowing anything to expect about my post-halo time.  He sent me home with instructions to wear a hard collar at all times and to see him again in about a month.

I began to swallow soon after my halo was removed, but I continued to have some minor shoulder discomfort.  Most of the skin from the base of my neck to the top of my arm and along my collar bone feels numb (I would almost describe it as a similar feeling to skin after it's been in extremely cold conditions for a while).  My range of motion and strength in that shoulder was very poor at the beginning.  Most worrying to me though is my neck looks crooked.  The best description I can give is that my neck itself appears slightly slanted to the my left, while my head is slightly slanted to my right.  The right side of my neck feels very tight.  During some movements (bending my neck forward or backward, for instance) I feel some slight pain or discomfort along the right side and sometimes there is a sharp pain near the base of my skull (still more on my right side).  I had another set of x-rays (5 weeks after halo removal) and saw my doctor again on 06/12.  Seen from the front, my c-spine is actually slightly curved to my left (I would describe it as a gradual and slight curve through the whole neck).  My doctor gave me a prescription for physical therapy (3x/week for 4 weeks) and told me to see him again in two months.  I'm set to start the therapy on 06/17.

I think I have fairly good mobility forward/backward and side to side, though still quite a bit of pain at the extremes of my motion, but barely anything turning, maybe 10 degrees to either side.  My shoulder seems to be improving slowly as I've spent some time lifting some light weights and stretching it each day.

My questions are:

Is the apparent curvature of my c-spine something I should be concerned about?  And why does my head tilt the opposite way of my neck?  I would think it would tilt the same way so as to be in line with the axis of my neck...  I was very worried, considering everything, that my doctor took me out of the halo too soon and that I could somehow reinjure my neck.  The right side is still very tight and sore.  I assume physical therapy will help with my range of motion and pain, but can it correct a curvature like this?

How fast do patients typically recover from these neck injuries in terms of returns of strength and range of motion?  How soon can I expect to do something like jogging or swimming again?  Anything you would recommend to help speed or ensure a healthy recovery?  What should I expect from my physical therapy so that I know they are doing their job as effectively as possible?  

What do you make of my shoulder?  Mechanically, it seems to work ok, but it still doesn't feel quite right, especially with the numbness.

Is my odontoid being "off" a cause for concern?  I read somewhere that something like for every inch out of optimal line you neck is, it effectively increases the weight it bears by the weight of you head.  Since the odontoid slipped forward, my head is also ever so slightly more forward too, and I'm worried for any long term effects this may have.

Answer
Dear Nicholas,

Well you have certainly got my eyes open this morning!!  Listen, you actually have a good chance for improving the spinal structure and getting much of your active range of  motion back, but this requires specific exercise protocols.  

Concerning the physical therapist(PT), your recovery will be limited to the extent of what the therapist really knows about the structure and placement of the spine.  Many do not have much training in this area and focus only on the functional aspects of rehab, as they are not primary care clinicians, and will have to rely on what your doctor has prescribed.  However, there are some very sharp physical therapists out there who have completed extra training and work diligently with their patients. Not to mention that PT's are really good at increasing function when they get accurate diagnostic criteria to work with. I would suggest that you interview the therapists before you start therapy and look at multiple PT clinics. One thing to realize though is that over 50% of the rotation in the neck arises from the upper cervical joints of the occiput/atlas/axis (C0/C1/C2). So with the scar tissue that is forming in that area, you may not be able to regain full movement.  I would expect you to get 75% back though.

Concerning the structure:  It is likely that when you fell on the neck that it buckled to the side as well as forward and that the ligaments were also damaged in the fall.  When you were in the halo, those ligaments had not rehab, and scar tissue was laid down without being formed along the lines of stress in the neck and this is probably why you have the curve along with the forward head translation.  This can be fixed with exercises and traction to target the structure of the curve, however it must be performed by someone with advanced training, and the placement of the odontoid must be specifically considered before the traction is implemented.  I am certified in structural rehab techniques, but I must say that I would be very cautious at the initial outset of utilizing traction in your case, and I would take flexion/extension x-rays of the neck first to make sure that you are completely stable around the odontoid first as the traction would require an extended head position for resolution.  You would also have to be watched carefully while in traction to make sure that there is not compression on the upper portion of the spinal cord.  If no compression exists, and there is no instability, then it should work well in your case.  You can read more about these techniques at www.idealspine.com.  They have a physician locater on the site to look for certified doctors in your area as well.  Last point:  The guru in this field is Dr. Deed Harrison, and he has been involved in over 50 papers on this topic...I would recommend that you speak to him personally about treatment options maybe in his clinic, or have him recommend someone close to your area.  You can contact him at Ruby Mountain Chiropractic Center (775)777-3033.

The shoulder problem is probably due to two things:  the fact that you were in a halo  which restricts your movement and function, as well as the fact that when you are in a halo, the nerves in the neck are in a fixed position and can become inflamed or irritated which can result in the altered sensation you have described.  This could be at the C5 nerve root itself which innervates the sensory aspects of the shoulder, or in the peripheral nerve supply.  The fact that you have full use of the shoulder though is a great sign because the motor portions of the nerve are located in the center...the sensory portions are in the periphery...this confirms more irritation than damage to the nerve.  Moreover, the abnormal placement of the neck to one side can create subtle tension in the nerve supply or compression which is enough to cause sensory disturbance such as numbness.  

Concerning the shoulder and the spine structure, Dr. Roger Sperry, (Nobel Prize Recipient for Brain Research) demonstrated that "the weight of a dime can reduce nerve function by 60%", so you can see how sensitive the structures are, and ?0% of the stimulation and nutrition to the brain is generated by the movement of the spine? Additionally, Dr. Sperry demonstrated that 90% of the energy output of the brain is used in relating the physical body to gravity.  Only 10% has to do with thinking, metabolism, and healing, so when you have forward head posture and a loss of active range of motion, your brain will rob energy from your thinking, metabolism, and immune function to deal with abnormal gravity and posture relationships and processing.  So, "YES" is it very important to work on the function as well as the structure of the spine...the physical therapist should be fine to work on the increased range of motion, by you should see a chiropractic physician for the structural part...one with advanced training in that area.

I would opine that you should be able to resume most of your normal activities in the next 6 weeks or so, however, your days on the trampoline should be over.  If you have another fall and fracture it could easily paralyze you.  I would stay away from contact sports as well, and focus on individual sports instead.  Hope everything foes well for you, fell free to write back if you feel the need.

Respectfully,
Dr. Shawn Leatherman
www.suncoasthealthcare.net