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Paul Oakley
Leesa Sanchez
Deed Harrison


Cervical Spine, Lordosis, MedicaL Imaging, Forward Head Posture


Objective: To compare medical radiologists’ subjective qualitative commentary on cervical spine alignment to the images’ actual quantitative and objective mensuration.

Methods: One-hundred-and-eight consecutive lateral cervical x-ray radiology reports were reviewed for commentary about cervical alignment. The radiographs were digitized and quantified into theoretical categories and compared to the commentary.

Results: Of the 100 images included for evaluation, 55 images had comments pertaining to ‘normal,’ 20 had ‘no comment,’ and 25 reports mentioned some sort of ‘abnormal’ alignment. Excessively hypolordotic/kyphotic necks were typically labeled as normal. Forward head posture and intersegmental kyphosis were frequently found in this patient sample but were never mentioned in a report even when in the severe range.

Conclusion: Medical radiologists in this study made generalized, non-specific comments regarding cervical lordosis, if mentioned at all. This suggests that they may not perceive the importance of cervical spine alignment as being involved in a patient’s complaint even when evidence suggests that cervical spine sagittal alignment is implicated in neck and headache symptomatology, physiological function, neurophysiological outcomes, and degenerative changes. This situation may fuel existing barriers between differing healthcare professionals as to how much emphasis should be placed on spinal alignment in the etiology of a patient’s cranio-cervical complaints.


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1. Takeshima T, Omokawa S, Takaoka T, et al. Sagittal alignment of cervical flexion and extension: lateral radiographic analysis. Spine 2002;27:E348-355
2. Takasaki H, Hall T, Kaneko S, et al. Radiographic analysis of the influence of initial neck posture on cervical segmental movement at end-range extension in asymptomatic subjects. Man Ther 2011;16:74-79
3. Miyazaki M, Hymanson HJ, Morishita Y, et al. Kinematic analysis of the relationship between sagittal alignment and disc degeneration in the cervical spine. Spine 2008;33:E870-876
4. Panjabi MM, Oda T, Crisco JJ 3rd, et al. Posture affects motion coupling patterns of the upper cervical spine. J Orthop Res 1993;11:525-536
5. Walmsley RP, Kimber P, Culham E. The effect of initial head position on active cervical axial rotation range of motion in two age populations. Spine 1996;21:2435-2442
6. Gum JL, Glassman SD, Douglas LR, et al. Correlation between cervical spine sagittal alignment and clinical outcome after anterior cervical discectomy and fusion. Am J Orthop (Belle Mead NJ) 2012;41:E81-84
7. McAviney J, Schulz D, Bock R, et al. Determining the relationship between cervical lordosis and neck complaints. J Manipulative Physiol Ther 2005;28:187-193
8. Harrison DD, Harrison DE, Janik TJ, et al. Modeling of the sagittal cervical spine as a method to discriminate hypo-lordosis: results of elliptical and circular modeling in 72 asymptomatic subjects, 52 acute neck pain subjects, and 70 chronic neck pain subjects. Spine 2004;29:2485-2492
9. Grosso MJ, Hwang R, Mroz T, et al. Relationship between degree of focal kyphosis correction and neurological outcomes for patients undergoing cervical deformity correction surgery. J Neurosurg Spine 2013;18:537-544
10. Kawakami M, Tamaki T, Yoshida M, et al. Axial symptoms and cervical alignments after cervical anterior spinal fusion for patients with cervical myelopathy. J Spinal Disord 1999;12:50-56
11. Naderi S, Ozgen S, Pamir MN, et al. Cervical spondylotic myelopathy: surgical results and factors affecting prognosis. Neurosurgery 1998;43:43-49
12. Okada E, Matsumoto M, Ichihara D, et al. Does the sagittal alignment of the cervical spine have an impact on disk degeneration? Minimum 10-year follow-up of asymptomatic volunteers. Eur Spine J 2009;18:1644-1651
13. Katsuura A, Hukuda S, Saruhashi Y, et al. Kyphotic malalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels. Eur Spine J 2001;10:320-324
14. Faldini C, Pagkrati S, Leonetti D, et al. Sagittal segmental alignment as predictor of adjacent-level degeneration after a cloward procedure. Clin Orthop Relat Res 2011;469:674-681
15. Park MS, Kelly MP, Lee DH, et al. Sagittal alignment as a predictor of clinical adjacent segment pathology requiring surgery after anterior cervical arthrodesis. Spine J 2014;14:1228-1234
16. Teo AQA, Thomas AC, Hey HWD. Sagittal alignment of the cervical spine: do we know enough for successful surgery? J Spine Surg. 2020 Mar;6(1):124-135.

17. Tundo F, Avila MJ, Willard L, Fanous S, Curri C, Hussain I, Baaj AA. Spinal alignment, surgery, and outcomes in cervical deformity: A practical guide to aid the spine surgeon. Clin Neurol Neurosurg. 2019 Oct;185:105496.

18. Ling FP, Chevillotte T, Leglise A, Thompson W, Bouthors C, Le Huec JC. Which parameters are relevant in sagittal balance analysis of the cervical spine? A literature review. Eur Spine J. 2018 Feb;27(Suppl 1):8-15.
19. Harrison DE, Harrison DD, Betz JJ, et al. Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial. J Manipulative Physiol Ther 2003;26:139-151
20. Harrison DE, Cailliet R, Harrison DD, et al. A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial. Arch Phys Med Rehabil 2002;83:447-453
21. Wickstrom BM, Oakley PA, Harrison DE. Non-surgical Relief of Cervical Radiculopathy through Reduction of Forward Head Posture and Restoration of Cervical Lordosis: A Case Report. J Phys Ther Sci 2017;29:1472-1474
22. Oakley P, Harrison D. Restoration of barefoot gait in a 75-year old female with cervical spondylotic myelopathy: A case report utilizing Chiropractic BioPhysics (CBP®) technique. Chiropr J Australia 2017;45:16-27
23. Moustafa IM, Diab AA, Harrison DE. The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study. Eur J Phys Rehabil Med 2017;53:57-71
24. Moustafa IM, Diab AA, Harrison DE. Does rehabilitation of cervical lordosis influence sagittal cervical spine flexion extension kinematics in cervical spondylotic radiculopathy subjects? J Back Musculoskelet Rehabil 2017;30:937-941
25. Moustafa IM, Diab AA, Taha S, et al. Addition of a Sagittal Cervical Posture Corrective Orthotic Device to a Multimodal Rehabilitation Program Improves Short- and Long-Term Outcomes in Patients With Discogenic Cervical Radiculopathy. Arch Phys Med Rehabil 2016;97:2034-2044
26. Gong W. The effects of cervical joint manipulation, based on passive motion analysis, on cervical lordosis, forward head posture, and cervical ROM in university students with abnormal posture of the cervical spine. J Phys Ther Sci 2015;27:1609-1611
27. Forrester DM, Nesson JW. The radiology of joint disease. Philadelphia: WB Saunders Co. 1973
28. Jackson FE: The Achilles’ neck and other vulnerable vertebrae. Emerg Med 1977;9:22-41
29. Williams CF, Bernstein TW, Jelenko C 3rd. Essentiality of the lateral cervical spine radiograph. Ann Emerg Med 1981;10:198-204
30. Yochum TR, Rowe LJ. Essentials of skeletal radiology. Vol. 1. Baltimore: Williams and Wilkins, 1987
31. Taylor JAM: Writing radiology reports in chiropractic. J Can Chiropr Assoc 1990;34:30-34.
32. Harrison DE, Harrison DD, Cailliet R. Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis. Spine 2000;25:2072-2078
33. Harrison DD, Janik TJ, Troyanovich SJ, et al. Comparisons of lordotic cervical spine curvatures to a theoretical ideal model of the static sagittal cervical spine. Spine 1996;21:667-675
34. Harrison DD, Janik TJ, Troyanovich SJ, et al. Evaluation of the assumptions used to derive an ideal normal cervical spine model. J Manipulative Physiol Ther 1997;20:246-256
35. Frymoyer JW, Phillips RB, Newberg AH, et al. A comparative analysis of the interpretations of lumbar spinal radiographs by chiropractors and medical doctors. Spine 1986;11:1020-1023
36. Tuck AM, Peterson CK. Accuracy and reliability of chiropractors and Anglo-European college of chiropractic students at visually estimating the lumbar lordosis from radiographs. Chiropr Tech 1998;10:19-26
37. Ajello M, Marengo N, Pilloni G, et al. Is it possible to evaluate the ideal cervical alignment for each patient needing surgery? An easy rule to determine the appropriate cervical lordosis in pre-operative planning. World Neurosurg 2017;97:471-478
38. Kettner NW, Guebert GM. The radiology of cervical spine injury. J Manipulative Physiol Ther 1991;14:518-526.
39. Tang JA, Scheer JK, Smith JS, et al. The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery 2012;71:662-669
40. Gehweiler JA Jr, Clark WM, Schaaf RE, et al. Cervical spine trauma: the common combined conditions. Radiology 1979;130:77-86
41. Clark WM, Gehweiler JA, Laib R. Twelve significant signs of cervical spine trauma. Skeletal Radiol 1979;3:201-205
42. Deltoff MN, Kogon PL. The portable skeletal x-ray library. St. Louis: Mosby. 1998, 247. ISBN: 978-0815122449
43. Harrison DE, Harrison DD, Troyanovich SJ. Reliability of spinal displacement analysis of plain X-rays: a review of commonly accepted facts and fallacies with implications for chiropractic education and technique. J Manipulative Physiol Ther 1998;21:252-266
44. Fedorchuk CA, McCoy M, Lightstone DF, et al. Impact of Isometric Contraction of Anterior Cervical Muscles on Cervical Lordosis. J Radiol Case Rep 2016;10:13-25
45. Phillips RB. The use of x-rays in spinal manipulative therapy. In: Haldeman S. editor. Modern developments in the principles and practice of chiropractic. New York: Appleton-Century Crofts; 1980: 189-209
46. Haas M, Taylor JAM, Gillette RG. The routine use of radiographic spinal displacement analysis: a dissent. J Manipulative Physiol Ther 1999;22:254-259
47. Gore DR. Roentgenographic findings in the cervical spine in asymptomatic persons: a ten-year follow-up. Spine 2001;26:2463-2466
48. Harrison DE, Harrison DD, Colloca CJ, et al. Repeatability over time of posture, radiograph positioning, and radiograph line drawing: an analysis of six control groups. J Manipulative Physiol Ther 2003;26:87-98
49. Hellsing E, McWilliam J, Reigo T, et al. The relationship between craniofacial morphology, head posture and spinal curvature in 8, 11 and 15-year-old children. Eur J Orthod 1987;9:254-264
50. Peng L, Cooke MS. Fifteen-year reproducibility of natural head posture: a longitudinal study. Am J Orthod Dentofac 1999;116:82-85
51. Cooke MS. Five-year reproducibility of natural head posture: a longitudinal study. Am J Orthod Dentofac 1990;97:489-494
52. Cooke MS, Wei SHY. The reproducibility of natural head posture: a methodological study. Am J Orthod Dentofac 1988;93:280-288
53. Hohl M. Soft-tissue injuries of the neck in automobile accidents. Factors influencing prognosis. J Bone Joint Surg Am 1974;56:1675-1682
54. Norris SH, Watt I. The prognosis of neck injuries resulting from rear-end vehicle collisions. J Bone Joint Surg Br 1983;65:608-611
55. Harrison DE, Harrison DD, Janik TJ, et al. Comparison of Axial and Flexural Stresses in Lordosis and Three Buckled Modes in the Cervical Spine. Clin Biomech 2001;16:276-284
56. Harrison DD, Jones EW, Janik TJ, et al. Evaluation of Flexural Stresses in the Vertebral body Cortex and Trabecular Bone in Three Cervical Configurations with an Elliptical Shell Model. J Manipulative Physiol Ther 2002;25:391-401
57. Sessumpun K, Paholpak P, Hindoyan KN, et al. Characteristics of cervical spine motion in different types of cervical alignment: kinematic MRI study. Clin Spine Surg 2018;31:E239-E244
58. Ruangchainkom M, Daubs MD, Suzuki A, et al. Effect of cervical kyphotic deformity type on the motion characteristics and dynamic spinal cord compression. Spine 2014;39:932-938