Journal of

Orthopaedic
Article Surger y
Journal of Orthopaedic Surgery
27(3) 1–5
ª The Author(s) 2019
Effect of cervical flexion and extension Article reuse guidelines:
sagepub.com/journals-permissions
on thoracic sagittal alignment DOI: 10.1177/2309499019876999
journals.sagepub.com/home/osj

Takamitsu Konishi, Kenji Endo, Takato Aihara , Yuji Matsuoka,

Hidekazu Suzuki, Taichiro Takamatsu, Takuya Kusakabe,
Yasunobu Sawaji, Hirosuke Nishimura, Kazuma Murata
and Kengo Yamamoto

Abstract
Introduction: The cervical spine has the largest sagittal motion in the whole spine, and cervical alignment affects the
thoracic sagittal alignment. However, the effects of cervical flexion and extension on thoracic sagittal alignment have not
been investigated in detail. The purpose of this study was to analyze the change of thoracic sagittal alignment following
cervical flexion and extension. Subjects and methods: A total of 55 consecutive patients (42 men and 13 women;
average age 49.1 years) who presented to our department with spinal degenerative disease between January 2016 and
September 2017 were enrolled in our study. Subjects with a history of trauma, infection, tumor, inflammatory disease,
ossification, or cervical deformities, and those who had undergone spinal surgery were excluded. The following para-
meters were analyzed: occipito-axial angle (O–C2), C2 slope (C2S), C2–C7 angle, T1 slope (T1S), thoracic kyphosis,
T1–T4 angle, T5–T8 angle, T9–T12 angle, lumbar lordosis, sacral slope, pelvic tilt in cervical flexion, neutral, and
extension. Results: Cervical flexion significantly decreased O–C2, C2–C7 angles and T1S, and increased C2S. Cervical
extension conversely changed these parameters. At cervical flexion, the correlation of C2–C7 angle with thoracic
parameters was maintained, except for the T1–T4 angle. At cervical extension, the correlation was observed with T1S and
T1–T4 angle. Conclusion: Cervical flexion affects the T1S and T5–T8 angle, but there is no significant change in T1–T4
and T9 and lower spino-pelvic columns. This study suggests that T2–T4 can be considered as a stable distal end when
cervical long fixation for corrective surgery is performed.

Keywords
cervical spine, sagittal spinal alignment, spine, thoracic spine

Date received: 29 December 2018; Received revised 9 August 2019; accepted: 18 August 2019

Introduction investigated in detail. In a clinical setting, we encountered

The change of cervical sagittal alignment affects and is
affected by other parameters of the spine in preserving
global sagittal alignment.1 The range of motion (ROM)
of the thoracic spine is restricted by the ribs,2 but the cer-
vical spine normally has the largest sagittal motion of the
whole spine, and cervical alignment affects thoracic sagit-
tal alignment. 1,3 Previously, only a few studies have
reported segmental ROM with regard to the thoracic sagit-
tal plane.2,4 The effects of cervical flexion and extension on
thoracic and lumbo-pelvic sagittal alignment have not been
angular movements of thoracic spine that could induce thor-
acic compressive myelopathy in ossification of posterior
Department of Orthopedic Surgery, Tokyo Medical University,
Shinjuku-ku, Tokyo, Japan
Corresponding author:
Takato Aihara, Department of Orthopedic Surgery, Tokyo Medical
University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan.
Email: aihara@fff.or.jp

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2 Journal of Orthopaedic Surgery 27(3)

Figure 1. (a) Global and (b) cervical sagittal spinal radiography at (a0 ) cervical flexion, (b0 ) neutral, and (c0 ) extension positions.
longitudinal ligament patients.5 Study of thoracic sagittal
alignment by cervical sagittal motion is important for the
treatment of thoracic alignment disorders. The purpose of
this study was to analyze the change of thoracic sagittal
alignment following cervical flexion and extension.
Materials and methods
A total of 55 consecutive patients (42 men and 13 women;
average age 49.1 years) who presented to our department
with spinal degenerative disease between January 2016 and
September 2017 were enrolled in our study. Subjects with a
history of trauma, infection, tumor, inflammatory disease,
ossification, or cervical deformities, and those who had
undergone spinal surgery were excluded. This study was
approved by the ethics review board of our institution.
Standing anteroposterior radiographs were taken in fists-
on-clavicles position with elbows fully flexed and fists
resting on clavicles in extended hip and knee position as
described previously.3,5,6 Lateral radiographs of the entire
vertebral column were taken in cervical flexion, neutral,
and extension (Figure 1(a)), and the reconstructed images
of the cervicothoracic junction were shown in Figure 1(b).
Subjects having difficulty with the radiographic procedures
Konishi et al. 3

due to maintaining the posture without support were (°)

excluded. The following global spinal radiographic para- 80
meters were measured in the standing position by computer 60 Flexion
association: occipito-axial angle (O–C2), angle between C2
40
lower endplate and horizontal plane (C2S), cervical lordo- Neutral
20
sis assessed by C2–C7 Cobb angle, which was defined as Extension
0
the angle from the lower endplate of C2 to the lower end-
plate of C7 (C2–7A), angle between T1 upper endplate and -20

horizontal plane (T1S), angle between T1 upper edge and -40

T12 lower edge (TK), T1–T4 angle, T5–T8 angle, T9–T12 -60
O-C2 (°) C2 S (°) C2 -7 A ( °)
angle, angle from upper endplate of L1 to upper endplate of P < 0 .0 5
sacrum (LL), angle between sacral plate and horizontal
plane (SS), angle between line connecting midpoint of Figure 2. Cervical sagittal alignments at cervical flexion, neutral,
sacral plate to axis of femoral head and gravity line (PT) and extension neck positions. Flexion and extension changed
in cervical flexion, neutral, and extension positions. Whole cervical alignments compared with neutral neck position. O–C2:
spine anteroposterior and lateral radiographs were obtained O–C2 angle, C2S: C2 slope, and C2–C7A: C2–C7 angle.
using digital slot-scanning radiography mode of the Sonial-
vision safire fluoroscopy system (Shimadzu Corporation,
(°)
Kyoto, Japan), and the association between changes in
60
parameters during cervical motion was analyzed. The intra-
and interobserver agreement rates of the measurements by 50
Flexion
this system have been described previously.6 40 Neutral
Values were expressed as mean + standard deviation
30 Extension
(SD). In determining the sample size of this study, we
referred to the number table by Cohen (Cohen, Psychol. 20
Bull., 1992)7 and used G*Power Analysis software version
10
3.1.9.4 (Heinrich-Heine University, Duüsseldorf, Ger-
many). We set the significance level (a err prob.) at 0.05, 0
T1S T 1 -4 A T 5 -8 A T 9 -1 2 A TK
the effect size f at 0.25, and the power (1  b err prob.) at
＊P < 0 .0 5
0.8, and this means that at least 159 samples were consid-
ered necessary. In this study, there were 55 patients with
three neck positions, and thus the total number for statisti- Figure 3. Thoracic alignments at cervical flexion, neutral, and
extension positions. There were no significant changes in the
cal analysis was 165 (55  3). Therefore, we think that the three cervical positions below the T1–T4 angle. T1S: T1 slope,
number of patients in this study was sufficient. Statistical T1–T4A: T1–T4 angle, T5–T8A: T5–T8 angle, and T9–T12A:
analyses were performed using the JMP software package T9–T12 angle. TK: thoracic kyphosis angle.
version 10.0 (SAS Institute Inc., Cary, North Carolina,
USA). Wilcoxon/Kruskal–Wallis tests were used to deter-
mine intergroup differences among cervical flexion, neu- (°)

tral, and extension to analyze the outcome measures of 60

parameters in sagittal spinal alignment. Correlations 50

between the variables of spino-pelvic parameters were ana- Flexion
40
lyzed by Spearman rank correlation coefficient. A p value Neutral
<0.05 was considered to indicate a statistically significant 30
Extension
difference between two groups. 20

Results
The cervical ROM in the standing position was 50.3 + 23.1 .
In cervical flexion, O–C2, C2–C7 angles and T1S were
significantly decreased, while C2S was increased. In con-
trast, in cervical extension, O–C2 and C2–C7 angles were
increased, while C2S was decreased (Figure 2). However,
T1–T4, T5–T8, T9–T12 angles and TK were not changed
significantly in cervical flexion and extension (Figure 3).
LL, PT, and SS were also not affected by cervical flexion
and extension (Figure 4). Regarding correlations among
10
0
LL SS PT PI
Figure 4. Lumbar alignments at cervical flexion, neutral, and
extension positions. Lumbar alignments did not change signifi-
cantly in the three cervical positions. LL: lumbar lordosis; SS:
sacral slope; PT: pelvic tilt; PI: pelvic incidence.
these parameters, in cervical flexion, C2–C7 angle corre-
lated with T1S and T5–T8 angle, but the correlation
between C2–C7 and T1–T4 angles had disappeared. In
4 Journal of Orthopaedic Surgery 27(3)
Table 1. Correlation between C2–C7 angle and thoracic sagittal
alignment at flexion, neutral, and extension cervical positions.a
Flexion Neutral Extension
T1 slope 0.47 (< 0.001)b 0.41 (0.002)b 0.50 (< 0.001)b
T1–T4 angle 0.01 (0.94) 0.05 (0.72) 0.27 (0.043)b
T5–T8 angle 0.27 (0.045)b 0.35 (0.0098)b 0.10 (0.48)
T9–T12 angle 0.09 (0.51) 0.24 (0.083) 0.21 (0.13)
a
p Values are given in parenthesis.
b
p < 0.05.
cervical extension, C2–C7 angle showed correlation with
T1S and T1–T4 angle but not with T5–T8 and T9–T12
angles (Table 1).
Discussion
It is known that the C2–C7 angle is well correlated with
T1S and global thoracic curvature in the up-right neutral
position.3,4 The present study demonstrated that cervical
sagittal motion affects the T1S and T5–T8 angle, but the
T1–T4 angle, T9–T12 angle, and lumbo-pelvic columns
did not change significantly. The reciprocal change of
T1–T4 angle was smaller than that of T5–T8 angle upon
cervical flexion and extension. The thoracic spine has lim-
ited ROM because of restriction by the ribs,2,8 but our
results showed no significant difference in thoracic sagittal
alignment between cervical flexion and extension. How-
ever, correlation between the C2–C7 angle and T1S,
T5–T8 angle was clear, and it should be taken into consid-
eration in terms of the effects of cervical dynamic factors.
The thoracic spine takes part in approximately 33% of
cervical flexion and 21% of cervical rotation and is closely
associated with cervical movement.9 In our results, cervical
sagittal alignment both in neutral and flexion/extension was
affected by T1S. At cervical extension position, T1S was
increased and T1–T4 angle had correlation to C2–C7 angle.
These may represent a thoracic compensation to maintain
balance by leaning forward slightly, as has also been
reported in previous studies.3,10 The thoracic spine has a
regional interdependence and its dysfunction affects symp-
toms of the cervical spine.11 The present study analyzed the
association between global sagittal spinal alignment and
cervical sagittal alignment in cervical flexion, neutral, and
extension. For a detailed analysis, the thoracic spine was
divided into three parts—T1–T4, T5–T8, and T9–T12.
Alignments of T1–T4 angle, T9–T12 angle, TK, LL, and
PT were not changed significantly by cervical flexion and
extension in comparison with neutral position. However,
T1S and T5–T8 angle positively correlated with C2–C7
angle at cervical neutral and flexion positions. These results
indicate that T1–T4 movement was less than that of T5–T8
during cervical movement and was relatively rigid follow-
ing cervical flexion. Morita et al., by computed tomography
scanning, showed that total ROM of thoracic spine (T1/L1)
was 31.7 + 11.3 and that segmental ROM decreased from
T1/T2 to T4/T5 but increased gradually from T4/T5 to
T12/L1.2 The stability of T1–T4 is supported by the pres-
ence of the shoulder girdle (scapula bone and rhomboid
muscles) because rhomboid minor and major muscles are
located from the scapula to C7–T5,12 and the role of those
back extensor muscles is particularly important. For cervi-
cal surgery strategy, those findings would represent very
useful information, as selection of the lower end in case of
posterior long fusion for cervical sagittal imbalance has
been a controversial issue due to anatomical and biomecha-
nical complexities of the cervicothoracic junction. The
present study showed that T1S correlated with C2–C7
angle at cervical flexion, neutral position, and extension
but that it was not correlated with T1–T4 angle at cervical
flexion and neutral positions. Therefore, when cervical
long fixation for corrective surgery is performed, the suit-
able distal end would be at T2, T3, or T4, but not at T1,
because T1 can be mobile by cervical motion.
The present study has some limitations, the first being
that measurement of the thoracic spine could not each ver-
tebra because of difficulty with the X-ray findings. A sec-
ond potential limitation was the fact that the clinical
findings in the subjects were not analyzed. A third limita-
tion was that the findings in this study only reflect the
situation at standing straight but not at other postures such
as sitting or stooping. Despite these limitations, our data
from a quantitative analysis standpoint could provide use-
ful basic information for considering the dynamic thoracic
sagittal movement by cervical sagittal motion as well as
present useful information to aid in the diagnosis and
decision-making of surgical strategy for cervicothoracic
spinal disease.
Conclusions
Cervical flexion affects the T1S and T5–T8 angle, while
the T1–T4 angle and the T9 and lower spino-pelvic col-
umns do not change significantly. This study suggests that
T2–T4 could be considered as a stable distal end when
cervical long fixation for corrective surgery is performed.
Acknowledgements
The authors are indebted to Mr Arndt Gerz for the editorial review
of the English manuscript. Advice and comments given by him
have been a great help to us. The authors are also grateful to Ms
Yuri Amamizu of the Department of Orthopedic Surgery for
assistance with preparation of the initial English manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Konishi et al.
ORCID iD
Takato Aihara https://orcid.org/0000-0001-5753-3033
Kazuma Murata https://orcid.org/0000-0002-9285-6142
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