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Normative values of cervical sagittal alignment according to global spine balance: based on 126 asymptomatic Chinese young adults

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Abstract

Purpose

To explore the normal distribution of cervical sagittal alignment and the relationship between cervical alignment and global spine balance in asymptomatic young adults.

Methods

A total of 67 males and 59 females aged from 18 to 30 years old were recruited from 11/2011 to 12/2014. The C0-C2 angle, disk angles from C2-C3 to C6-C7, vertebral angles from C3 to C7, T1 slope, thoracic kyphosis (TK), lumbar lordosis, pelvic incidence, sacral slope, C2-C7 sagittal vertical axis (SVA), center of gravity of head to C7 SVA (CGH-C7SVA), C7-S1SVA were measured and statistically analyzed. The Roussouly classification was utilized.

Results

Mean value of C0-C7 was 26.0° ± 12.8°, composed of 15.2° ± 6.7° for C0-C2, 9.1° ± 12.1° for sum of disk angles from C2-C3 to C6-C7, and 1.4° ± 10.2° for sum of vertebral angles from C3 to C7. C2-C7SVA (18.6 mm ± 7.9 mm) and CGH-C7SVA (22.9 mm ± 12.3 mm) were offset ideally by C7-S1SVA (-21.6 mm ± 31.0 mm). Significant difference was found between cervical alignment of different Roussouly types (p < 0.01). There was significant correlation between cervical alignment and T1 slope (p < 0.01), TK (p < 0.01). There was significant correlation between adjacent segmental angles from T1 slope up to C0-C2 angle (p < 0.05).

Conclusion

Normative values of each vertebral angle and disk angle were established. The cervical lordosis occurred mainly at C0-C2 and disk levels, which was influenced by parameters of other parts of the spine, such as T1 slope, TK and the Roussouly classification. There was significant correlation between adjacent disk angles.

Level of evidence I

Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

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Data availability

The related data was available by contact with the corresponding author.

References

  1. Le Huec JC, Demezon H, Aunoble S (2015) Sagittal parameters of global cervical balance using EOS imaging: normative values from a prospective cohort of asymptomatic volunteers. Eur Spine J Off Publ Eur Spine Soc Eur Spin Deform Soc Eur Sect Cerv Spine Res Soc 24(1):63–71. https://doi.org/10.1007/s00586-014-3632-0

    Article  Google Scholar 

  2. Lee SH, Son ES, Seo EM, Suk KS, Kim KT (2015) Factors determining cervical spine sagittal balance in asymptomatic adults: correlation with spinopelvic balance and thoracic inlet alignment. The Spine J Off J North Am Spine Soc 15(4):705–712. https://doi.org/10.1016/j.spinee.2013.06.059

    Article  Google Scholar 

  3. Nunez-Pereira S, Hitzl W, Bullmann V, Meier O, Koller H (2015) Sagittal balance of the cervical spine: an analysis of occipitocervical and spinopelvic interdependence, with C-7 slope as a marker of cervical and spinopelvic alignment. J Neurosurg Spine 23(1):16–23. https://doi.org/10.3171/2014.11.SPINE14368

    Article  PubMed  Google Scholar 

  4. Sakai K, Yoshii T, Hirai T, Arai Y, Torigoe I, Tomori M, Sato H, Okawa A (2016) Cervical sagittal imbalance is a predictor of kyphotic deformity after laminoplasty in cervical spondylotic myelopathy patients without preoperative kyphotic alignment. Spine 41(4):299–305. https://doi.org/10.1097/BRS.0000000000001206

    Article  PubMed  Google Scholar 

  5. Kato M, Namikawa T, Matsumura A, Konishi S, Nakamura H (2017) Effect of cervical sagittal balance on laminoplasty in patients with cervical myelopathy. Glob Spine J 7(2):154–161. https://doi.org/10.1177/2192568217694011

    Article  Google Scholar 

  6. Theologis AA, Iyer S, Lenke LG, Sides BA, Kim HJ, Kelly MP (2019) Cervical and cervicothoracic sagittal alignment according to Roussouly thoracolumbar subtypes. Spine 44(11):E634-e639. https://doi.org/10.1097/brs.0000000000002941

    Article  PubMed  Google Scholar 

  7. Pepke W, Almansour H, Lafage R, Diebo BG, Wiedenhofer B, Schwab F, Lafage V, Akbar M (2019) Cervical spine alignment following surgery for adolescent idiopathic scoliosis (AIS): a pre-to-post analysis of 81 patients. BMC Surg 19(1):7. https://doi.org/10.1186/s12893-019-0471-2

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Khalil N, Bizdikian AJ, Bakouny Z, Salameh M, Bou Zeid N, Yared F, Otayek J, Kharrat K, Kreichati G, Ghanem I, Lafage R, Lafage V, Obeid I, Assi A (2018) Cervical and postural strategies for maintaining horizontal gaze in asymptomatic adults. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 27(11):2700–2709. https://doi.org/10.1007/s00586-018-5753-3

    Article  Google Scholar 

  9. Yu M, Zhao W-K, Li M, Wang S-B, Sun Y, Jiang L, Wei F, Liu X-G, Zeng L, Liu Z-J (2015) Analysis of cervical and global spine alignment under Roussouly sagittal classification in Chinese cervical spondylotic patients and asymptomatic subjects. Eur Spine J 24(6):1265–1273

    Article  Google Scholar 

  10. Hardacker JW, Shuford RF, Capicotto PN, Pryor PW (1997) Radiographic standing cervical segmental alignment in adult volunteers without neck symptoms. Spine 22(13):1472–1480

    Article  CAS  Google Scholar 

  11. Ohara A, Miyamoto K, Naganawa T, Matsumoto K, Shimizu K (2006) Reliabilities of and correlations among five standard methods of assessing the sagittal alignment of the cervical spine. Spine 31(22):2585

    Article  Google Scholar 

  12. Roussouly P, Gollogly S, Berthonnaud E, Dimnet J (2005) Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine 30(3):1558

    Article  Google Scholar 

  13. Diebo BG, Challier V, Henry JK, Oren JH, Spiegel MA, Vira S, Tanzi EM, Liabaud B, Lafage R, Protopsaltis TS, Errico TJ, Schwab FJ, Lafage V (2016) Predicting cervical alignment required to maintain horizontal gaze based on global spinal alignment. Spine 41(23):1795–1800. https://doi.org/10.1097/BRS.0000000000001698

    Article  PubMed  PubMed Central  Google Scholar 

  14. Patwardhan AG, Khayatzadeh S, Havey RM, Voronov LI, Smith ZA, Kalmanson O, Ghanayem AJ, Sears W (2018) Cervical sagittal balance: a biomechanical perspective can help clinical practice. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 27(Suppl 1):25–38. https://doi.org/10.1007/s00586-017-5367-1

    Article  Google Scholar 

  15. Nori S, Shiraishi T, Aoyama R, Ninomiya K, Yamane J, Kitamura K, Ueda S (2018) Upper cervical lordosis compensates lower cervical kyphosis to maintain whole cervical lordosis after selective laminectomy. J Clin Neurosci Off J Neurosurg Soc Australasia 58:64–69. https://doi.org/10.1016/j.jocn.2018.10.049

    Article  Google Scholar 

  16. Kim JT, Lee HJ, Choi DY, Shin MH, Hong JT (2016) Sequential alignment change of the cervical spine after anterior cervical discectomy and fusion in the lower cervical spine. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 25(7):2223–2232. https://doi.org/10.1007/s00586-016-4401-z

    Article  Google Scholar 

  17. Kim JH, Park JY, Yi S, Kim KH, Kuh SU, Chin DK, Kim KS, Cho YE (2015) Anterior cervical discectomy and fusion alters whole-spine sagittal alignment. Yonsei Med J 56(4):1060–1070. https://doi.org/10.3349/ymj.2015.56.4.1060

    Article  PubMed  PubMed Central  Google Scholar 

  18. Tang R, Ye IB, Cheung ZB, Kim JS, Cho SK (2019) Age-related changes in cervical sagittal alignment: a radiographic analysis. Spine 44(19):E1144–E1150. https://doi.org/10.1097/BRS.0000000000003082

    Article  PubMed  Google Scholar 

  19. Iyer S, Lenke LG, Nemani VM, Fu M, Shifflett GD, Albert TJ, Sides BA, Metz LN, Cunningham ME, Kim HJ (2016) Variations in occipitocervical and cervicothoracic alignment parameters based on age: a prospective study of asymptomatic volunteers using full-body radiographs. Spine 41(23):1837–1844. https://doi.org/10.1097/BRS.0000000000001644

    Article  PubMed  Google Scholar 

  20. Yang BS, Lee SK, Song KS, Yoon SP, Jang G, Lee CC, Moon SH, Lee HM, Lee SH (2015) The use of T1 sagittal angle in predicting cervical disc degeneration. Asian Spine J 9(5):757–761. https://doi.org/10.4184/asj.2015.9.5.757

    Article  PubMed  PubMed Central  Google Scholar 

  21. Mac-Thiong JM, Roussouly P, Berthonnaud E, Guigui P (2010) Sagittal parameters of global spinal balance: normative values from a prospective cohort of seven hundred nine Caucasian asymptomatic adults. Spine 35(22):E1193-1198. https://doi.org/10.1097/BRS.0b013e3181e50808

    Article  PubMed  Google Scholar 

  22. Lee CS, Chung SS, Kang KC, Park SJ, Shin SK (2011) Normal patterns of sagittal alignment of the spine in young adults radiological analysis in a Korean population. Spine 36(25):E1648-1654. https://doi.org/10.1097/BRS.0b013e318216b0fd

    Article  PubMed  Google Scholar 

  23. Zhu Z, Xu L, Zhu F, Jiang L, Wang Z, Liu Z, Qian BP, Qiu Y (2014) Sagittal alignment of spine and pelvis in asymptomatic adults: norms in Chinese populations. Spine 39(1):E1-6. https://doi.org/10.1097/brs.0000000000000022

    Article  PubMed  Google Scholar 

  24. Mac-Thiong JM (2016) Normal sagittal parameters of global spinal balance in children and adolescents: a prospective study of 646 asymptomatic subjects. Eur Spine J 25(11):3650–3657

    Article  Google Scholar 

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Funding

No funds were received in support of this work.

Author information

Authors and Affiliations

  1. Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Street, HaiDian District, Beijing, 100191, China

    Yanchao Tang, Xiaoguang Liu & Miao Yu

  2. Beijing Key Laboratory of Spinal Disease Research and Engineering, Beijing, China

    Yanchao Tang, Xiaoguang Liu & Miao Yu

  3. Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China

    Yanchao Tang, Xiaoguang Liu & Miao Yu

  4. Pain Medicine Center of Peking University Third Hospital, Beijing, China

    Wenkui Zhao & Xiaoguang Liu

Authors
  1. Yanchao Tang
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  2. Wenkui Zhao
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  3. Xiaoguang Liu
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  4. Miao Yu
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Yanchao Tang and Wenkui Zhao. The first draft of the manuscript was written by Yanchao Tang and critically revised by Miao Yu and Xiaoguang Liu. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Miao Yu.

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There was no conflict of interest/competing interest about this work. The manuscript submitted does not contain information about medical device(s)/drug(s). No relevant financial activities outside the submitted work.

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Informed consent for publication had been obtained. There was only analytic information about the participants’ X-rays and no identifying details.

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This study was approved by our institutional review board.

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Tang, Y., Zhao, W., Liu, X. et al. Normative values of cervical sagittal alignment according to global spine balance: based on 126 asymptomatic Chinese young adults. Eur Spine J 30, 2427–2433 (2021). https://doi.org/10.1007/s00586-021-06756-w

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  • DOI: https://doi.org/10.1007/s00586-021-06756-w

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