The Influence of Thoracic Inlet Alignment on the Craniocervical Sagittal Balance in Asymptomatic Adults

Study Design: A prospective radiographic study. Objectives: To analyze the relationship between craniocervical sagittal balance and thoracic inlet (TI) alignment and to present the parameters that would help predict physiological lordosis of the cervical spine. Summary of Background Data: The physiological cervical lordosis (CL) and related factors has not been clearly defined yet. No studies have reported correlations between TI alignment and sagittal balance of the cervical spine. Methods: Cervical spine lateral radiograph of 77 asymptomatic adult volunteers (aged between 21 and 50 y) were taken to analyze the following parameters. (1) Thoracic inlet parameters: thoracic inlet angle (TIA), T1 slope, neck tilting (NT); (2) cervical spine parameters: C0-2 angle, C2-7 angle, % ratio of (C0-2/C0-7 angle), (C2-7/C0-7 angle), and cervical tilting; (3) cranial parameters: C0 angle, cranial offset, and cranial tilting. Statistical analysis was performed using the Pearson correlation coefficients and multiple regression analysis. Results: The mean TIA, T1 slope, NT were 69.5, 25.7, and 43.7, respectively. The mean C0-2 angle, C2-7 angle, C0 angle, cranial offset, cervical tilting, and cranial tilting were -22.4 degrees, -9.9 degrees, -9.3 degrees, 20.9mm, 18 degrees, and 7.7 degrees, respectively. The ratio of C0-2:C2-7 angle was maintained as 77:23% and cervical tilting: cranial tilting was 70.2:29.8%. A significant correlation was found between TIA and T1 slope (r = 0.694), T1 slope and C2-7 angle (r = -0.624), C2-7 angle and C0-2 angle (r = -0.547), C0-2 angle and cranial offset (r = -0.406). Conclusions: The thoracic inlet alignment had significant correlations with craniocervical sagittal balance. To preserve physiological NT around 44 degrees, large TIA increased T1 slope and CL and vice versa. TIA and T1 slope could be used as parameters to predict physiological alignment of the cervical spine. The results of this study may serve as baseline data for the evaluation of sagittal balance or planning of a fusion angle in the cervical spine.