Original Article http://dx.doi.org/10.

1590/S1808-185120222202265303

Degenerative

ANALYSIS OF CERVICAL SAGITTAL BALANCE IN PATIENTS NECK

PAIN AND NO NECK PAIN
ANÁLISE DO EQUILÍBRIO SAGITAL CERVICAL EM PACIENTES COM E SEM CERVICALGIA

ANÁLISIS DEL EQUILIBRIO SAGITAL CERVICAL EN PACIENTES CON Y SIN CERVICALGIA

Vania Maria Lima1,2,3 , Marcio Cley Fernandes dos Reis2 , Nilson Mozas Olivares4 , Guilherme Reiff Toller1 , Daniel Jose Mazzo Bedran
1 1
de Castro , Orlando Rafael de Andrade Madrid
1. Faculdades Integradas da Fundação Padre Albino (UNIFIPA), Department of Orthopedics and Traumatology, Catanduva, São Paulo, Brazil.
2. Hospital Adventista Pênfigo, Department of Orthopedics and Traumatology (Spine Surgery - HAP), Campo Grande, Mato Grosso do Sul, Brazil.
3. Residency Service in Orthopedics and Traumatology - Spine Surgery Resident (MEC) - Hospital Governador Celso Ramos- (HGCR), Florianópolis, Santa Catarina, Brazil.
4. Faculdades Integradas da Fundação Padre Albino (UNIFIPA), Department of Statistics, Medical School, Catanduva, São Paulo, Brazil.

ABSTRACT
Introduction: Sagittal balance was measured by Hardacker`s et al. using the occipital method COBB C1-C2, C2-C3, C3-C4, C4-C5,
C5-C6, C6-C7 in a sample of asymptomatic patients without neck and shoulder pain. In other recent studies, measurements of cervical
sagittal balance included several radiographic parameters. Objective: To compare the cervical sagittal balance in groups of patients with
and without neck pain submitted to cervical radiography, with the upper limbs in flexion. Methods: This is a cross-sectional, quantitative,
prospective, descriptive study with radiographic analysis of 50 adults aged between 30 to 70 years old. The group was divided into Group
1: without neck pain, and Group 2: with neck pain. All answered a questionnaire about age and the presence or absence of neck pain.
Exclusion criteria were: inadequate X-Ray image, deformity or previous spine surgery, limited shoulder mobility, and individuals younger
than 30 and older than 70. The radiographic parameters evaluated were: COBB, TIA ( THORACIC INLET ANGLE), T1 SLOPE, NECKTILT,
and COG-C7 with no neck pain. α = 5% (significance when p <0.05). Results: The MANN WHITNEY nonparametric test showed no
significant differences between Cobb GROUPS (p= 0.7452), T1 SLOPE GROUPS (p=0.1410), NECKTILT GROUPS (p=0.0852) and
GROUPS THORACIC INLET ANGLE (p=0.1789). Conclusion: There was a significant difference only between COG-C7 GROUPS (cm)
(p=0.0013). The analysis of the obtained data showed statistical significance in the variation in the COG-C7 groups. Level of Evidence II;
Prospective comparative study.

Keywords: Postural balance; Radiography; Neck pain.

RESUMO
Introdução: O equilíbrio sagital foi medido por Hardacker et al. usando o método occipital COBB C1-C2, C2-C3, C3-C4, C4-C5, C5-
C6, C6-C7 em uma amostra de pacientes assintomáticos sem dor no pescoço e no ombro. Em outros estudos recentes, as medidas do
equilíbrio sagital cervical incluíram vários parâmetros radiográficos. Objetivo: Comparar o equilíbrio sagital cervical em grupos de pacientes
com cervicalgia e sem cervicalgia submetidos à radiografia da cervical, com os membros superiores em flexão. Métodos: Trata-se de um
estudo transversal, quantitativo, prospectivo, descritivo, com análise radiográfica de 50 adultos, com idade entre 30 e 70 anos. O grupo foi
dividido em Grupo 1: sem cervicalgia e Grupo 2: com cervicalgia. Todos responderam a um questionário sobre idade e presença ou não
de dor cervical. Os critérios de exclusão foram: imagem inadequada, deformidade ou cirurgia prévia da coluna, mobilidade limitada do
ombro e indivíduos com idade inferior a 30 e superior a 70 anos. Os parâmetros radiográficos avaliados foram: COBB, TIA (ANG THORACIC
INLET), T1 SLOPE, NECKTILT e COG-C7 com e sem cervicalgia. α = 5% (significância quando p < 0,05). Resultados: O teste não para-
métrico de MANN WHITNEY não mostrou diferenças significativas entre os GRUPOS Cobb (p= 0,7452), GRUPOS SLOPE T1 (p=0,1410),
GRUPOS NECKTILT (p=0,0852) e GRUPOS TIA (p=0,1789). Conclusão: Houve diferença significativa apenas entre os GRUPOS COG-C7
(cm) (p=0,0013). A análise dos dados obtidos demonstrou significância estatística em relação à variação nos grupos COG-C7. Nível de
evidência II; Estudo comparativo prospectivo.

Descritores: Equilíbrio postural; Radiografia; Cervicalgia.

RESUMEN
Introcucción: El equilibrio sagital fue medido por Hardacker et al. utilizando el método occipital COBB C1-C2, C2-C3, C3-C4, C4-C5,
C5-C6, C6-C7 en una muestra de pacientes asintomáticos sin dolor del cuello y hombros. En otros estudios recientes, las mediciones del
equilibrio sagital cervical incluyeron varios parámetros radiográficos. Objetivo: Comparar el equilibrio sagital cervical en grupos de pacientes
con y sin cervicalgia sometidos a radiografía cervical, con los miembros superiores en flexión. Metodos: Se trata de un estudio transversal,
cuantitativo, prospectivo, descriptivo, con análisis radiográfico de 50 adultos, con edades entre 30 y 70 años. El grupo compartió el Grupo
1: Sin dolor del cuello y el Grupo 2: Dolor de cuello. Todos respondieron un cuestionario sobre edad, dolor de cuello o ausencia de dolor

Study conducted by the Orthopedics and Traumatology Department of Hospital Padre Albino (HPA), Catanduva, São Paulo, Brazil.
Correspondence: Vania Maria Lima. 1745, Ave. Paulista. Conj. 1213, São Paulo, SP, Brazil. 01311-200. [email protected].

Page 1 of 7
Received on 06/28/2022 accepted on 09/23/2022
Coluna/Columna. 2023;22(2):e265303 Reviewed by: Erasmo Abreu Zardo
de cuello. Los criterios de exclusión fueron: imagen inadecuada, deformidad o cirugía previa de columna, movilidad limitada del hombro y
menores de 30 años y mayores de 70 años. Los parámetros radiográficos evaluados fueron: Cobb, TIA (ANG TORACIC INLET), T1 SLOPE,
NECKTILT y COG-C7 con y sin cervicalgia. α = 5% (significación cuando p < 0,05). Resultados: La prueba no paramétrica de MANN
WHITNEY no mostró diferencias significativas entre los GRUPOS COBB (p=0,7452), GRUPOS T1 SLOPE (p=0,1410), GRUPOS NECKTILT
(p=0,0852) y GRUPOS ANG TORACIC INLET (p=0,1789). Conclusión: Hubo diferencia significativa solo entre los GRUPOS COG-C7 (cm)
(p=0,0013). El análisis de los datos obtenidos mostró significancia estática en relación a la variación en los grupos COG-C7. Nivel de
Evidencia II; Estudio prospectivo comparativo.

Descriptores: Equilibrio postural; Radiografía; Dolor de cuello.

INTRODUCTION and 10 (the worst pain). In this study, we standardized the radiogra-
phs with the arms elevated in 90° flexion with the elbows extended,
The sagittal balance and normative parameters of the cervico-
both in the standing position and looking forward.10 The patients
thoracic junction are established, and its normal parameters can gui-
were positioned one and a half meters from the collimator, close
de the surgical correction of deformities in this vertebral segment.1
to the chassis (Figure 1).10 All images were obtained by a single
It is based on the alignment between the vertebral segments.2-4 It
radiology technician. The study divided the patients into inclusion
is a parameter evaluated by physical and radiographic examination
and exclusion criteria groups (Figure 2).
and is an important study of spinal diseases and indications for
The Vestatech Hecra D-0005-Toshiba device was used for this
surgical treatment.
study. The angles were measured by goniometer (Figure 3)10 and
Recently, the importance of cervical sagittal balance has been
evaluated by the authors, and the radiographic parameters consi-
demonstrated, and its deformity is associated with, for example, pain,
dered for the study were:
functional disability, and even the severity of cervical myelopathy.3
1. Cervical lordosis (LC) from the COBB method, based on lines pa-
Sagittal balance was measured by Hardacker et al.5 using
rallel to the lower endplates of C2 and C7, measuring in degrees.11-15
the COBB C1-C2, C2-C3, C3-C4, C4-C5, C5-C6, C6-C7 occipital
2. Tilt angle of T1: angle between a tangent line on the upper-end
method in a sample of asymptomatic patients without complaints
plate of T1 and the horizontal plane, measured in degrees.11-15
of the cervical spine and shoulder pain.5 In other recent studies,
measurements of cervical sagittal balance have included various
radiographic parameters. These include the T1 slope or T1 tilt (T1
SLOPE), C1-C2 lordosis, C2-C7, the sagittal vertical axis (SVA), and
the C7-T1 slope.4,6,7
Lee et al.4 studied lateral cervical spine radiographs in 77 asymp-
tomatic patients aged 21 to 50. The following parameters were
evaluated: (1) thoracic entry parameters: thoracic inlet angle (TIA),
T1 slope (T1 SLOPE), and neck tilt (NECKTILT); (2) cervical spine
parameters: C2-C7 and C0-C7 angles. Iyer et al.8 (2016) recruited
120 asymptomatic adults between 18 and 79 years old, excluding
people with cervicalgia, and performed a cervical sagittal balance
measurement.
The study aims to analyze the parameters used in evaluating
cervical sagittal balance in patients with and without cervicalgia
who underwent panoramic radiography of the spine in profile with
shoulders in flexion. This study is relevant because of the paucity
of such analyses in the literature.

METHODS
This is a cross-sectional, quantitative, descriptive, prospective
study of radiographic analyses of the cervical spine in profile with Figure 1. Lateral cervical spine radiograph, with arms elevated horizontally in
the arms elevated horizontally in 90° flexion in a standing position. 90° orthostatic flexion.10
The subjects were volunteers between 30 and 70 years old who
were seen in the Department of Orthopedics and Traumatology
Age range 30 to 70 Patients younger than 30 or older than years of
from August to October 2020. The study was approved by the CEP age
years
(Research Ethics Committee of Faculdades Integradas Fundação
Patients evaluated from Know presence of spinal deformity that would
Padre Albino), and the approval opinion was registered under num-
August to Octuber 2020 make radiological analysis difficult
ber: 34634820900005430, approved on July 08, 2020.
The patients were informed about the study and were free to join. Patients treat at the HPA Patients who underwent previous spine surgery
The group signed the Informed Consent Form. They answered the Patients submitted to
Technically inadequate radiographs
questionnaire regarding age, presence or absence of cervicalgia, radiografic study of the
and degree of cervical spine pain. Patients who authorized radio- spine performed in the
graphs were included in the study, with full care taken to maintain radiology department
medical confidentiality. They were ensured similar treatment condi- Technically adequate Patients with glenohumeral pain or limitation
tions to the other patients in the service, obtaining neither exclusive
radiographs
benefits nor prejudices in the medical management of their patho-
Patients who answered Patients who refused to participate in the research
logies. In addition, the patients involved in the study consented to
the questionnaire and did not fill out the questionnaire
the publication of the obtained data and images in a scientific study,
provided their identity was preserved. Patients who signed the Patients who after filing out the ICF and the
Pain intensity was analyzed using a Likert scale based on the Vi- informed Consent Form questionnaire desisted from undergoing the
examination
sual Analog and Facial Scales.9 In the study by Lima et al.,10 pain was
stratified into zero (no pain), 1 to 4 (mild pain), 5 to 9 (moderate pain), Figure 2. Inclusion and exclusion criteria of the study.

Page 2 of 7
ANALYSIS OF CERVICAL SAGITTAL BALANCE IN PATIENTS NECK PAIN AND NO NECK PAIN

3. Thoracic Inlet Angle (TIA): delimited by the body of the first thora- RESULTS
cic vertebra toward the manubrium and a straight line perpendicular
Fifty male patients were interviewed. They were distributed into two
to the upper limit of the sternal jugular notch and by the first ribs and groups of 25 patients. Group1: No neck pain and Group 2: Neck pain.
the upper edge of the first thoracic vertebra.11-13 Then Tables 2, 3, 4, and 5 show the descriptive analysis of the study.
4. The Necktilt angle is defined as an angle between two lines origi- Figures 4, 5, 6, 7, and 8 BoxPlot below refer to angles evaluated
nating in the upper region of the sternum, one vertical and the other neck pain and no neck pain. Com cervicalgia= Neck pain and sem
connecting the sternum to the center of the T1 endplate.12,13,15,16 cervicalgia= No neck pain.
5. COG is measured using a line perpendicular to the ground and The following figure depicts the normality test for quantitative
the head’s center of gravity. On lateral radiographs, the COG can be variables of the Sagittal Balance study analyzed No neck pain and
measured using the anterior portion of the external auditory pinna Neck pain (Figure 9). Com cervicalgia= Neck pain and sem cervi-
as the starting point to the posterosuperior aspect of the vertebral calgia= No neck pain.
body of C7 measured in millimeters.12,14,15
The authors performed the radiographic analyses in an attempt to DISCUSSION
avoid bias. They are grouped into groups of patients with cervicalgia
and without cervicalgia after the questionnaire evaluation answer. Were The spine is responsible for several functions, which gives it an
impressive degree of complexity. Didactically segmented, it can be
compared in two groups: Group 1: without cervicalgia and Group 2:
divided into three major segments, with the cervical segment allo-
with cervicalgia. The variables are COBB, COG-C7, T1 SLOPE= T1
wing the integration of the head with the rest of the axial skeleton.4
INCLINATION, THORACIC INLET ANGLE (TIA), and NECKTILT. The The mobility of the upper limbs and the ability to steady and
data obtained in the wo groups have been distributed in Table 1. move the head are directly related to the cervical spine15 and the
A statistical analysis demonstrating Mean, Median, Mode, structures surrounding it.
Standard Deviation, and paired T-test for the difference between Attention has been devoted to the relationships between the
the mean, with 5% significance. It used graphs by Boxplot system, occipital region, the vertebral segments of the cervical spine, and
which identifies possible variables: the minimum, first quartile (Q1), the alignment of these structures17,18 with each other and the spine
median, third quartile (Q3), and maximum. For the comparison be- as a whole. This set of relationships, which can be measured and
tween groups 1 and 2, significance was considered when (p<0.05). unfolded in different ways and angulations through specific radiogra-
phic examinations, is defined as the sagittal balance of the cervical
spine,6 also described long ago as sagittal balance.1
As knowledge has developed regarding the concept of the spine
COG-C7 as a set of structures that work uniformly while respecting a balance
of forces acting on the vertebral structures to keep the skeleton
moving and in balance, more attention has been devoted to the
COBB
sagittal balance of the spine.8,11,19
Initially, the studies focused on a more pronounced knowledge
Inclination T1
of the lumbosacral region, but the so-called cervical sagittal balance
Neck tilt has also demonstrated more modern importance.
Angle Among some of these relationships described are Cervical Lor-
In let
thoracic
dosis (LC), T1 SLOPE, Thoracic Inlet Angle (TIA), NeckTilt Angle, and
COG-C7, and these angulations and measurements are defined as
detailed above.11,13,14
Several studies have defined a standard for what is considered
normal or physiological in these parameters, with publications des-
cribing and establishing what relationships are considered “normal”.
Figure 3. Schematic Angles: COBB, Necktilt, T1 Slope (Inclination T1), Thoracic Such relationships are increasingly used in decisions regarding the
Inlet Angle, and COG-C7.10 development of therapies and surgical procedures.3,17

Table 1. Statistical description Sagittal balance of patients neck pain and no neck pain. COBB; COG-C7; NECKTILT; THORACIC INLET ANGLE AND
T1 SLOPE.
Maximum
Mean ± SD. Minimum Value Q1 Median Q3
Value
No neck Neck No neck Neck No neck Neck No neck Neck No neck Neck
Variable n No neck pain Neck pain p
pain pain pain pain pain pain pain pain pain pain
COBB (cm) 25 35,44±4,5 34,88±4,9 30 22 32 32 34 34 40 40 42 40 0,7452
COG C0-C7
25 11,28±0,9 10,52±0,7 9 9 11 10 11 10 12 11 12 11,5 0,0013*
(cm)
Neck tilt (cm) 25 39,4±3,3 40,88±3,1 32 32 38 39 40 40 42 43 46 48 0,0852
Thoracic Inlet
25 78,24±6 76,72±4,4 65 70 75 72 80 76 82 81 88 84 0,1789
Angle
T1 Slope 25 20,8±2,2 22,24±2,9 16 18 19 20 22 22 22 24 24 28 0,1410

Table 2. Statistical Description: COBB; COG-C7; NECKTILT; THORACIC INLET ANGLE; T1 SLOPE No neck pain.
Variable Total Count Mean St Dey Minimum Q1 Median Q3 Maximum
COBB 25 35,440 491 30,000 32,000 34,000 40,000 42,000
COG-C7 (cm) 25 11,280 0,879 9,000 11,000 11,000 12,000 12,500
Necktilt 25 39,400 3,291 32,000 38,000 40,000 42,000 46,000
Thoracic Inlet Angle 25 78,24 5,99 65,00 75,00 80,00 82,00 88,00
T1 Slope 25 20,800 2,236 16,000 19,000 22,000 22,000 24,000

Page 3 of 7
Table 3. Statistical Description: COBB; COG-C7; NECKTILT; THORACIC INLET ANGLE; T1 SLOPE Neck pain.
Variable Total Count Mean St Dey Minimum Q1 Median Q3 Maximum
COBB 25 34,880 4,868 22,000 32,000 34,000 40,000 40,000
COG-C7 (cm) 25 10,520 0,653 9,000 10,000 10,500 11,000 11,500
Necktilt 25 40,880 3,113 32,000 39,000 40,000 43,000 48,000
Thoracic Inlet Angle 25 76,720 4,430 70,000 72,000 76,000 81,000 84,000
T1 Slope 25 22,240 2,905 18,000 20,000 22,000 24,000 28,000

Table 4. Sagittal balance: COBB; COG-C7; NECKTILT; THORACIC INLET Table 5. Sagittal balance: COBB; COG-C7; NECKTILT; THORACIC INLET
ANGLE; T1 SLOPE Neck pain. ANGLE; T1 SLOPE No neck pain.
Thoracic Inlet Thoracic Inlet
Patients COBB COG-C7 Necktilt T T1 Slope Patients COBB COG-C7 Necktilt T T1 Slope
Angle Angle
1 32 10,5 cm 38 72 18 1 30 9 cm 32 88 24
2 22 9.5 cm 40 74 20 2 32 11 cm 36 68 18
3 32 10,5 cm 38 82 22 3 34 11,5 cm 38 74 24
4 40 10 cm 40 82 20 4 40 10 cm 44 80 20
5 40 11,5 cm 42 84 22 5 34 10 cm 46 83 20
6 40 10,5 cm 44 72 24 6 40 10,5 cm 40 65 24
7 38 9 cm 38 72 20 7 30 11 cm 34 82 22
8 34 11 cm 38 78 28 8 42 10,5 cm 38 76 24
9 32 11 cm 38 80 20 9 32 11 cm 40 78 22
10 40 11,5 cm 32 72 22 10 42 12 cm 44 84 22
11 40 11 cm 40 76 28 11 34 12,5 cm 40 82 20
12 40 11 cm 44 78 28 12 32 12,5 cm 36 84 22
13 34 10 cm 48 84 24 13 36 11 cm 40 82 22
14 32 11,5 cm 40 72 24 14 42 12,5 cm 42 78 22
15 30 10,5 cm 42 72 20 15 34 12 cm 38 82 18
16 40 10,5 cm 44 76 20 16 38 11 cm 44 82 22
17 38 10,5 cm 42 80 22 17 30 12 cm 38 72 18
18 40 11 cm 42 82 20 18 40 11 cm 39 82 18
19 38 11 cm 44 76 22 19 40 12 cm 42 82 22
20 34 10 cm 44 72 22 20 42 11 cm 38 68 22
21 32 10,5 cm 40 76 24 21 38 12 cm 40 78 16
22 28 10 cm 42 70 20 22 30 12 cm 42 76 20
23 36 10 cm 40 82 18 23 32 12 cm 36 68 18
24 30 9.5 cm 40 80 22 24 32 11 cm 38 82 20
25 30 11 cm 42 74 26 25 30 11 cm 40 80 20

Figure 4. The non-parametric MANN WHITNEY test showed no significant Figure 5. The nonparametric MANN WHITNEY test showed no significant
differences between the COBB Neck pain and No neck pain GROUPS differences between NECKTILT Neck pain and No neck pain GROUPS
(p = 0.7452). (p =0.0852).

Back pain is very common in daily clinical practice.18 The com- values and measures related to cervical sagittal balance when com-
plaint of chronic neck pain is quite common in the office and may pared to those evaluated in asymptomatic patients.
reach an incidence of up to 30% of the complaints related to the spi- In this study, the radiographic examination was performed by
ne.4,7 These manifestations are not necessarily related to diseases the same radiographer to avoid bias. Observing the results obtai-
that cause severe and progressive deformities in the cervical spine. ned in the present study, we verified that the Cobb values found in
Since this is a more prolonged pain condition, possible altera- asymptomatic patients about those who presented complaints of
tions involving the forces to which the cervical spine is subjected can neck pain were not statistically significant, that is, P>0.05, in the
be expected, which could lead to differences between the angular various statistical tests analyzed.

Page 4 of 7
ANALYSIS OF CERVICAL SAGITTAL BALANCE IN PATIENTS NECK PAIN AND NO NECK PAIN

According to Been (2017),15 adequate cervical lordosis is essen-

tial for efficient chewing function, breath control, vocal production,
and eye movement and serves as part of the shock absorption
mechanism during walking and running. The loss of normal cervical
curvature may be associated with pain, temporomandibular joint
dysfunction, and other disorders.15,16,19 Thus, changes in Cobb an-
gulation would be expected in patients with cervicalgia, which was
not observed in the study in question.
The reciprocal can be questioned despite a well-established
relationship of morphological changes in the cervical spine triggering
pain. This is because the cervical pain reported in the offices is
associated with muscular factors with direct influence from emotional
issues, vicious positions, and ergonomic alterations,16 and not ne-
cessarily with morphological alterations of this vertebral segment.20
Analogous reasoning can be seen in the analyses of other angle
patterns such as T1 SLOPE Angle, Thoracic Inlet Angle (TIA), and
NeckTilt Angle. As previously discussed, such measures are often
Figure 6. The non-parametric MANN WHITNEY test showed no significant diffe-
associated with deformities related to diseases affecting the cervical
rences between T1 SLOPE Neck pain and No neck pain GROUPS (p =0.1410).
spine and lead to pain. In this case, the exclusion criterion of patients
with known spinal deformities may have been responsible for not
having a significant angular difference.
However, there was a statistical difference, with important variation
in the so-called COG-C7 distance, that is, the distance between the
center of gravity of the head and C7. In patients with chronic cervical-
gia, the COG-C7 distance was shorter than in asymptomatic patients.
The decrease in this distance can be related to two main factors:
1. Changes are directly seen in the cervical spine, such as degene-
rative disc changes where disc dehydration processes could lead
to such variation;
2. Changes from external elements to the intrinsic structures of the
spine, such as exacerbated muscle contracture in this region, which
is extremely frequent in patients with chronic neck pain.20
The sum of these two situations would often contribute syner-
gistically as an influencing factor in the change of this evaluated
parameter. Thus, we verified that the presence of cervical pain, by
Figure 7. The non-parametric MANN WHITNEY test showed no significant itself, would not trigger changes in sagittal balance but could be
differences between THORACIC INLET ANGLE Neck pain and No neck pain related to changes in COG-C7 measurements.
GROUPS.
CONCLUSION
The data analysis showed static significance concerning the
variation in the COG-C7 groups, being greater in the group without
cervicalgia. This difference does not alter the cervical sagittal ba-
lance. Further studies should be carried out to prove this finding.
The study showed a limitation in the number of participants due to
the pandemic period.

ACKNOWLEDGEMENTS
Marilete Karim Luzia Pedreiro Biagi, secretary, and Joana Cândi-
da Miranda (admirable plaster technician); both helped with printing
the x-rays as scheduling the exams.

All authors declare no potential conflict of interest related to

Figure 8. The non-parametric MANN WHITNEY test showed significant diffe-
rences between COG C0-C7 (cm) No neck pain and Neck pain (p = 0.0013).
this article.

CONTRIBUTIONS OF THE AUTHORS: Each author contributed individually and significantly to the development of this manuscript. Study concept
and design: VML. Data Acquisition and REC Approval: VML, MCFR. Statistics: NMO. Data analysis and interpretation: VML, MCFR, GRT, and NMO.
Article Development: VML, MCFR, NMO, and GRT. A critical review of the article: GRT and MCFR. Review the final submission version: VML, MCFR,
GRT, DJMB, NMO, and ORA.

REFERENCES
1. Theologis AA, Iyer S, Lenke LG, Sides BA, Kim HJ, Kelly MP. Cervical and Cervicotho- evaluation of the adult spinal deformity patient. Neurosurg Clin N Am. 2013;24(2):143-56.
racic Sagittal Alignment According to Roussouly’s Thoracolumbar Subtypes. Spine. 3. Wang ZL, Xiao JL, Mou JH, Qin TZ, Liu P. Analysis of Cervical Sagittal Balance Parameters in
2019;44(11):E634-9. MRI sof Patients with Disc-Degenerative Disease. Med Sci Monit. 2015;21:3083-8.
2. Smith JS, Shaffrey CI, Fu KM, Scheer JK, Bess S, Lafage V, et al. Clinical and radiographic 4. Lee SH, Son ES, Seo EM, Suk KS, Kim KT. Factors determining cervical spine sagittal balance

Page 5 of 7
Figure 9. Test of normality for quantitative variables of the Sagittal Balance study analyzed No neck pain and Neck pain.

Page 6 of 7
ANALYSIS OF CERVICAL SAGITTAL BALANCE IN PATIENTS NECK PAIN AND NO NECK PAIN

in a symptomatic adults: Correlation with spinopelvic balance and thoracic in let alignment. Delta-Omega-analysis. PloSOne. 2017;12(4):1-14.
Spine. 2015;15(4):705-12. 13. Lima MC, Risso NMI, Zuani GR, Veiga IG, Tebet MA, Pasqualini W, et al. Parâmetros de avalia-
5. Hardacker JW, Shuford RF, Capicotto PN, Pryor PW. Radiographic standing cervical seg- ção do equilíbrio sagital cervical na escoliose idiopática. Coluna/Columna. 2017;16(1):38-41.
mental alignment in adult volunteers without neck symptoms. Spine. 1997;22(13):1472-80. 14. Tang JA, Scheer JK, Smith JS, Deviren V, Bess S, Hart RA, et al. The impact of standing
6. Ozdogan S, Koken M, Duzkalir HG, Duzkalir AH, Yaltirik CK, Ozturk E, et al. Brief review on regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neuro-
fundamentals of cervical spine alignment. J Turk Spinal Surg. 2017;28(1):53-60. surgery. 2012;71(3):662-9.
7. Siasios I, Winograd E, Khan A, Vakharia K, Dimopoulos VG, Pollina J. Cervical sagittal balance 15. Been E, Shefi S, Soudack M. Cervical lordosis: the effect of age and gender. Spine.
parameters after single-level anterior cervical discectomy and fusion: Correlations with clini- 2017;17(6):880-8. Doi: 10.1016/j.spinee.2017.02.007.
cal and functional out comes. J Cranio vertebr Junction Spine. 2018;9(1):56-62. 16. Yim J, Park J, Lohman E, Do K. Comparison of cervical muscle activity and spinal curvatures
8. Iyer S, Lenke LG, Nemani VM, Fu M, Shifflett GD, Albert TJ, et al. Variations in Occipito- in the sitting position with 3 different sloping seats. Medicine. 2020;99(28):e21178.
cervical and Cervicothoracic Alignment Parameters Based on Age: A Prospective Study 17. Batista Junior JL, Batista PR, Barbosa DM, Machado IC, Rezende R. Evaluation of cervi-
of Asymptomatic Volunteers Using Full-Body Radiographs. Spine. 2016;41(23):1837-44. cal behavior in patients with scoliosis Lenke who underwent surgery. Coluna/Columna.
9. Lima DP, Sties SW, Gonzales AI, Bundchen DC, Aquino IG, Carvalho T de, et al. Questionário 2011;10(3):231-3.
para avaliação da dor musculoesquelética em praticantes de exercício (Q-ADOM). Rev Bras 18. Soares JC, Weber P, Trevisan ME, Trevisan CM, Rossi AG . Correlação entre postura da
Med Esporte. 2016;22(5):374-80. cabeça, intensidade da dor e índice de incapacidade cervical em mulheres com queixa de
10. Lima VM, Toller GR, Olivares NM. Comparative Analysis of Cervical Sagittal Balance with Ra- dor cervical. Fisioter Pesqui. 2012;19(1):68-72.
diographs in Different Postures. Coluna/Columna. 2021;20(1):20-5. Doi: 10.1590/S1808- 19. Shao ZX, Yan YZ, Pan XX, Chen SQ, Fang X, Chen XB, et al. Factors associated with cervical
185120212001227533. spine alignment in an asymptomatic population. World Neurosurg. 2019;122:48-58. Doi:
11. Colachis SC Jr, Strohm BR. Radiographic studies of cervical spinemotion in normal subjects: 10.1016/j. wneu.2018.09.036 .
flexion and hyperextension. Arch Phys Med Rehabil. 1965;46:753-60. 20. Patwardhan AG, Khayatzadeh S, Havey RM, Voronov LI, Smith ZA, Kalmanson O, et al.
12. Koeppen D, Piepenbrock C, Kroppenstedt S, Cabraja M. The influence of sagittal profile Cervical sagittal balance: a biomechanical perspective can help clinical practice. Eur Spine J.
alteration and final lordosis on the clinical outcome of cervical spondylotic myelopathy. A 2017;27(Suppl 1):25-38. Doi: 10.1007/s00586-017-5367-1.

Page 7 of 7