{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T21:18:33Z","timestamp":1790716713565,"version":"4.1.0"},"reference-count":26,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["SPI"],"published-print":{"date-parts":[[2015,7]]},"abstract":"<jats:sec>\n<jats:title>OBJECT<\/jats:title>\n<jats:p>Sagittal malalignment of the cervical spine has been associated with worsened postsurgical outcomes. For better operative planning of fusion and alignment restoration, improved knowledge of ideal fusion angles and interdependences between upper and lower cervical spine alignment is needed. Because spinal and spinopelvic parameters might play a role in cervical sagittal alignment, their associations should be studied in depth.<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>METHODS<\/jats:title>\n<jats:p>The authors retrospectively analyzed digital lateral standing cervical radiographs of 145 patients (34 asymptomatic, 74 symptomatic; 37 surgically treated), including full-standing radiographs obtained in 45 of these patients. Sagittal measurements were as follows: C2\u20137, occiput (Oc)\u2013C2, C1\u20132 Cobb angles, and C-7 slope (the angle between the horizontal line and the superior endplate of C-7), as well as T4\u201312 and L1\u2013S1 Cobb angles, sacral slope, pelvic incidence, and C-7 sagittal vertical axis (SVA). A correlation analysis was performed, and linear regression models were developed.<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>RESULTS<\/jats:title>\n<jats:p>Statistical analyses revealed significant correlations between C2\u20137 and Oc\u2013C2 (r = \u22120.4, p &lt; 0.01), Oc\u2013C2 (r = \u22120.3, p &lt; 0.01), and C1\u20132 angle (r = \u22120.3, p &lt; 0.01). C-7 slope was significantly correlated with C2\u20137 (r = \u22120.5, p &lt; 0.01) and with Oc\u2013C2 angle (r = 0.2, p = 0.02). Total cervical (Oc\u2013C7) lordosis was 30.2\u00b0 and did not differ significantly among asymptomatic, symptomatic, and surgically treated patients. Correlations between C2\u20137 and Oc\u2013C2 alignment were stronger in asymptomatic patients (r = \u20130.5, p &lt; 0.01) and surgically treated patients (r = \u20130.5, p &lt; 0.01) than in symptomatic patients (r = \u20130.3, p = 0.01), but the between-group difference was not significant (p &gt; 0.1). Comparing cervical and spinopelvic alignment revealed a significant correlation between sacral slope and C-7 slope (r = \u20130.3, p = 0.04) and C2\u20137 (r = 0.4, p &lt; 0.01). The C-7 SVA correlated significantly with the C-7 slope (r = \u20130.4, p &lt; 0.01). The interdependences were stronger within the occipitocervical parameters than between the cervical and remaining spinal parameters.<\/jats:p><\/jats:sec>\n<jats:sec>\n<jats:title>CONCLUSIONS<\/jats:title>\n<jats:p>Significant correlations between the upper and lower cervical spine exist, confirming the existence of inherent compensatory mechanisms to maintain overall balance; no significant differences were found among asymptomatic, symptomatic, and surgically treated patients. The C-7 slope is a useful marker of overall sagittal alignment, acting as a link between the occipitocervical and thoracolumbar spine.<\/jats:p><\/jats:sec>","DOI":"10.3171\/2014.11.spine14368","type":"journal-article","created":{"date-parts":[[2015,4,24]],"date-time":"2015-04-24T14:12:18Z","timestamp":1429884738000},"page":"16-23","source":"Crossref","is-referenced-by-count":98,"title":["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"],"prefix":"10.3171","volume":"23","author":[{"given":"Susan","family":"N\u00fa\u00f1ez-Pereira","sequence":"first","affiliation":[{"name":"Spine Surgery Department, St. Franziskus-Hospital, Cologne, Germany;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wolfgang","family":"Hitzl","sequence":"additional","affiliation":[{"name":"Research Office, Biostatistics, Paracelsus Medical University, Salzburg, Austria; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Viola","family":"Bullmann","sequence":"additional","affiliation":[{"name":"Spine Surgery Department, St. Franziskus-Hospital, Cologne, Germany;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oliver","family":"Meier","sequence":"additional","affiliation":[{"name":"German Scoliosis Center Bad Wildungen, Bad Wildungen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Heiko","family":"Koller","sequence":"additional","affiliation":[{"name":"German Scoliosis Center Bad Wildungen, Bad Wildungen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1-spine14368","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"1141","DOI":"10.1007\/s00586-011-1837-z","article-title":"Cervical spine sagittal alignment variations following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis","volume":"20","author":"Canavese","year":"2011"},{"issue":"1 Suppl Spine","key":"b2-spine14368","series-title":"J Neurosurg","first-page":"13","article-title":"Anterior correction of cervical kyphotic deformity: effects on myelopathy, neck pain, and sagittal alignment","volume":"100","author":"Ferch","year":"2004"},{"key":"b3-spine14368","series-title":"Am J Orthop","first-page":"E81","article-title":"Correlation between cervical spine sagittal alignment and clinical outcome after anterior cervical discectomy and fusion","volume":"41","author":"Gum","year":"2012"},{"key":"b4-spine14368","series-title":"Arch Orthop Trauma Surg","doi-asserted-by":"publisher","first-page":"857","DOI":"10.1007\/s00402-011-1265-x","article-title":"Relation between alignments of upper and subaxial cervical spine: a radiological study","volume":"131","author":"Guo","year":"2011"},{"key":"b5-spine14368","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"2072","DOI":"10.1097\/00007632-200008150-00011","article-title":"Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis","volume":"25","author":"Harrison","year":"2000"},{"key":"b6-spine14368","series-title":"J Neurosurg Spine","doi-asserted-by":"publisher","first-page":"491","DOI":"10.3171\/2011.6.SPINE1012","article-title":"Cervical sagittal plane decompensation after surgery for adolescent idiopathic scoliosis: an effect imparted by postoperative thoracic hypokyphosis","volume":"15","author":"Hwang","year":"2011"},{"key":"b7-spine14368","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"330","DOI":"10.1007\/s00586-012-2493-7","article-title":"Sagittal alignment of the cervical spine in adolescent idiopathic scoliosis treated by posteromedial translation","volume":"22","author":"Ilharreborde","year":"2013"},{"key":"b8-spine14368","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"869","DOI":"10.1007\/s00586-009-0945-5","article-title":"Subaxial subluxation after atlantoaxial transarticular screw fixation in rheumatoid patients","volume":"18","author":"Ito","year":"2009"},{"key":"b9-spine14368","series-title":"Spine J","doi-asserted-by":"publisher","first-page":"994","DOI":"10.1016\/j.spinee.2010.08.031","article-title":"The use of the T1 sagittal angle in predicting overall sagittal balance of the spine","volume":"10","author":"Knott","year":"2010"},{"key":"b10-spine14368","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"2055","DOI":"10.1007\/s00586-007-0398-7","article-title":"4- and 5-level anterior fusions of the cervical spine: review of literature and clinical results","volume":"16","author":"Koller","year":"2007"},{"key":"b11-spine14368","series-title":"J Neurosurg Spine","doi-asserted-by":"publisher","first-page":"104","DOI":"10.3171\/spi.2007.6.2.104","article-title":"Neutral upright sagittal spinal alignment from the occiput to the pelvis in asymptomatic adults: a review and resynthesis of the literature","volume":"6","author":"Kuntz","year":"2007"},{"key":"b12-spine14368","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"1037","DOI":"10.1097\/BRS.0b013e3181eb9469","article-title":"Spino-pelvic parameters after surgery can be predicted: a preliminary formula and validation of standing alignment","volume":"36","author":"Lafage","year":"2011"},{"issue":"Suppl 5","key":"b13-spine14368","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"699","DOI":"10.1007\/s00586-011-1938-8","article-title":"Sagittal imbalance cascade for simple degenerative spine and consequences: algorithm of decision for appropriate treatment","volume":"20","author":"Le Huec","year":"2011"},{"key":"b14-spine14368","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"161","DOI":"10.1097\/00007632-200101150-00010","article-title":"Significance of occipitoaxial angle in subaxial lesion after occipitocervical fusion","volume":"26","author":"Matsunaga","year":"2001"},{"key":"b15-spine14368","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"765","DOI":"10.1097\/00007632-199704010-00011","article-title":"Biomechanical analysis of buckling alignment of the cervical spine. Predictive value for subaxial subluxation after occipitocervical fusion","volume":"22","author":"Matsunaga","year":"1997"},{"key":"b16-spine14368","series-title":"Am J Roentgenol Radium Ther Nucl Med","first-page":"23","article-title":"Occipitalization of the atlas","volume":"70","author":"McRae","year":"1953"},{"key":"b17-spine14368","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"1644","DOI":"10.1007\/s00586-009-1095-5","article-title":"Does the sagittal alignment of the cervical spine have an impact on disk degeneration? Minimum 10-year follow-up of asymptomatic volunteers","volume":"18","author":"Okada","year":"2009"},{"key":"b18-spine14368","series-title":"J Spinal Disord Tech","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1097\/BSD.0b013e31823097f9","article-title":"Relationship between the alignment of the occipitoaxial and subaxial cervical spine in patients with congenital atlantoxial dislocations","volume":"26","author":"Passias","year":"2013"},{"issue":"Suppl 2","key":"b19-spine14368","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"S203","DOI":"10.1007\/s00586-012-2571-x","article-title":"Pre- and postoperative sagittal balance in idiopathic scoliosis: a comparison over the ages of two cohorts of 132 adolescents and 52 adults","volume":"22","author":"Roussouly","year":"2013"},{"key":"b20-spine14368","series-title":"Neurol India","doi-asserted-by":"publisher","first-page":"264","DOI":"10.4103\/0028-3886.27149","article-title":"Clinical implications of alignment of upper and lower cervical spine","volume":"54","author":"Sherekar","year":"2006"},{"key":"b21-spine14368","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"E204","DOI":"10.1097\/00007632-200405150-00022","article-title":"Measurement of occipitocervical angle","volume":"29","author":"Shoda","year":"2004"},{"issue":"1 Supp1 1","key":"b22-spine14368","series-title":"Neurosurgery","first-page":"S90","article-title":"Cervical deformity correction","volume":"60","author":"Steinmetz","year":"2007"},{"key":"b23-spine14368","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"662","DOI":"10.1227\/NEU.0b013e31826100c9","article-title":"The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery","volume":"71","author":"Tang","year":"2012"},{"key":"b24-spine14368","series-title":"J Neurosurg Spine","doi-asserted-by":"publisher","first-page":"521","DOI":"10.3171\/2009.2.SPINE08385","article-title":"Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: outcome after anterior or posterior decompression","volume":"11","author":"Uchida","year":"2009"},{"key":"b25-spine14368","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"E714","DOI":"10.1097\/BRS.0b013e3182444402","article-title":"Comparison of sagittal spinopelvic alignment in Chinese adolescents with and without idiopathic thoracic scoliosis","volume":"37","author":"Yong","year":"2012"},{"key":"b26-spine14368","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"175","DOI":"10.1097\/01.BRS.0000107225.97653.CA","article-title":"A retrospective radiographic analysis of subaxial sagittal alignment after posterior C1-C2 fusion","volume":"29","author":"Yoshimoto","year":"2004"}],"container-title":["Journal of Neurosurgery: Spine"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-spine\/23\/1\/article-p16.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-spine\/23\/1\/article-p16.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-spine\/23\/1\/article-p16.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,4,15]],"date-time":"2023-04-15T21:44:16Z","timestamp":1681595056000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-spine\/23\/1\/article-p16.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2015,7]]},"references-count":26,"journal-issue":{"issue":"1"},"URL":"https:\/\/doi.org\/10.3171\/2014.11.spine14368","relation":{},"ISSN":["1547-5654"],"issn-type":[{"value":"1547-5654","type":"print"}],"subject":[],"published":{"date-parts":[[2015,7]]}}}