Impact of cervical sagittal balance and cervical spine alignment on craniocervical junction motion: an analysis using upright multi-positional MRI



To evaluate the effect of cervical sagittal alignment on craniocervical junction kinematic.


We retrospectively reviewed 359 patients (119 cervical lordosis, 38 cervical sagittal imbalances, 111 cervical straight, and 91 cervical kyphosis) who underwent cervical spine multi-positional magnetic resonance imaging (mMRI). The C2-7 angle, disc degeneration grading and cSVA were analyzed in neutral position. The C3-5 OCI, O-C2 angle, and OCD were analyzed in neutral, flexion, and extension position. The Kruskal–Wallis test was used to detect difference among four groups. The post hoc analysis was performed by Mann–Whitney U test.


The cervical sagittal imbalance, cervical straight, and cervical kyphosis groups had significantly more lordosis angle in C3 and C4 OCI and O-C2 angle than the cervical lordosis group (p < 0.0125). Head motion in relation to C2, C3, and C4 (O-C2 angle, C3-4 OCI) in the kyphosis group was significantly greater than in the cervical lordosis group (p < 0.0125). The cervical sagittal imbalance group showed significantly increased O-C2 angle than the cervical lordosis group (p = 0.008). Regression analysis showed that an increase in O-C2 angle by one unit had a relative risk of 4.3% and 3.5% for a patient to be in the cervical sagittal imbalance and cervical kyphosis groups, respectively.


Cervical sagittal alignment affected craniocervical junction motion with the head exhibiting greater extension and motion in the cervical sagittal imbalance and cervical kyphosis groups. Motion of the head in relation to C2 can be used to predict the cervical sagittal alignment.

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Correspondence to Zorica Buser.

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There are not conflicts of interest, and disclosures outside of submitted work were provided in the Conflict of Interest forms. Disclosures outside of submitted work: JCW- Royalties – Biomet, Seaspine, Amedica, DePuy Synthes; Investments/Options – Bone Biologics, Pearldiver, Electrocore, Surgitech; Board of Directors - North American Spine Society, AO Foundation (20,000 honorariums for board position, plus travel for board meetings), Cervical Spine Research Society; Editorial Boards - Spine, The Spine Journal, Clinical Spine Surgery, Global Spine Journal; Fellowship Funding (paid directly to institution): AO Foundation; ZB- consultancy: Cerapedics, The Scripps Research Institute, Xenco Medical (past), AO Spine (past); Research Support: SeaSpine (past, paid to the institution), Next Science (paid directly to institution), Motion Metrix (paid directly to institution); North American Spine Society: committee member; Lumbar Spine Society: Co-chair Research committee, AOSpine Knowledge Forum Degenerative: Associate member; AOSNA Research committee- committee member.

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Paholpak, P., Vega, A., Formanek, B. et al. Impact of cervical sagittal balance and cervical spine alignment on craniocervical junction motion: an analysis using upright multi-positional MRI. Eur Spine J 30, 444–453 (2021).

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  • Cervical sagittal alignment
  • Multi-positional MRI
  • Craniocervical junction
  • Head motion