{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,24]],"date-time":"2026-02-24T15:09:27Z","timestamp":1771945767351,"version":"3.50.1"},"reference-count":68,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,2,24]],"date-time":"2026-02-24T00:00:00Z","timestamp":1771891200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Bioengineering"],"abstract":"<jats:p>Diagnosing cervical spine instability with flexion-extension radiographs is challenging, as current guidelines are based on limited cadaver studies and do not adequately account for level, vertebral size, or patient effort. There is a need for automated cervical instability metrics anchored to normative reference data, accompanied by evidence on how often abnormal findings occur in real clinical populations and which soft-tissue injury patterns they can detect. We developed and evaluated fully automated, radiographic-based cervical intervertebral motion (IVM) metrics\u2014adapted from prior lumbar methods\u2014using an FDA-cleared analysis pipeline that segments C2\u2013C7 and derives rotation, translation, disc heights, and regression-based instability indices. Normative reference data were first established from flexion-extension radiographs of 341 asymptomatic volunteers after excluding radiographically degenerated levels. Abnormality prevalence was then estimated in two symptomatic cohorts: pooled preoperative clinical-trial radiographs and 881 patients with symptoms attributed to motor-vehicle accidents, excluding levels with &lt;5\u00b0 rotation to reduce unreliable data due to insufficiently stressed spines. Finally, potential diagnostic performance was assessed in a controlled cadaveric ligament-sectioning model (12 cadavers) using ROC analysis and Youden\u2019s J thresholds. Across clinical cohorts, objective IVM abnormalities were uncommon. Prevalence increased when studies demonstrated adequate total C2\u2013C7 motion, emphasizing the importance of patient effort. In cadavers, vertical instability metrics were most discriminative (AUC 0.96\u20130.97) with high sensitivity (0.89) and perfect specificity at optimal thresholds, whereas translation changed minimally with sectioning. These results support regression-based instability indices as promising candidates for standardized, physiology-guided cervical instability assessment.<\/jats:p>","DOI":"10.3390\/bioengineering13030258","type":"journal-article","created":{"date-parts":[[2026,2,24]],"date-time":"2026-02-24T13:53:20Z","timestamp":1771941200000},"page":"258","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Automated Metrics for the Diagnosis of Instability Between the 2nd and 7th Cervical Vertebrae"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2008-3523","authenticated-orcid":false,"given":"John","family":"Hipp","sequence":"first","affiliation":[{"name":"Medical Metrics, Houston, TX 77057, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Charles","family":"Reitman","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery and Rehabilitation, Medical University of South Carolina, Charleston, SC 29425, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christopher","family":"Chaput","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mathew","family":"Gornet","sequence":"additional","affiliation":[{"name":"The Orthopedic Center of St. Louis, Chesterfield, MO 63017, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8631-9845","authenticated-orcid":false,"given":"Trevor","family":"Grieco","sequence":"additional","affiliation":[{"name":"Medical Metrics, Houston, TX 77057, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,24]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1097\/00003086-197506000-00011","article-title":"Biomechanical analysis of clinical stability in the cervical spine","volume":"109","author":"White","year":"1975","journal-title":"Clin. 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