Neutral upright sagittal spinal alignment from the occiput to the pelvis in asymptomatic adults: a review and resynthesis of the literature

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An increasing emphasis is being placed on the preservation or restoration of neutral upright sagittal spinal alignment in both deformity surgery and routine spinal operations. Sagittal spinal alignment is becoming recognized as an important predictor of a patient’s outcome after spinal surgery. In this literature review, the authors analyze data obtained from previously published studies conducted to evaluate neutral upright sagittal spinal alignment from the occiput to the pelvis in asymptomatic adults.


A review of the English-language literature was conducted to identify studies conducted to evaluate neutral upright sagittal spinal (occiput–pelvis) alignment in asymptomatic adult volunteers with no spinal disease. The authors identified 12 articles that met the strict primary inclusion criteria of the current study. From these articles, 23 angles and displacements were selected to depict neutral upright sagittal occiput–pelvis alignment. Pooled estimates of the mean and variance were calculated for angles and displacements that met secondary inclusion criteria. The greatest variation in the regional spinal curves occurred in the cervical spine from C-2 to C-7, whereas the greatest focal angulation in the spine occurred from L-4 to S-1. Sagittal spinal balance was maintained in a narrow range for alignment of the spine over the pelvis and femoral heads.


Neutral upright sagittal occiput–pelvis alignment in asymptomatic adults has been well studied regionally. Despite a wide variation in the undulating lordotic and kyphotic regional curves from the occiput to the pelvis, sagittal spinal balance is maintained in a narrower range for alignment of the spine over the pelvis and femoral heads.

Abbreviations used in this paper:CBVA = Chin-brow to vertical angle; HA = hip axis; SD = standard deviation; STA = sagittal tilt angle; SVA = sagittal vertical axis; VB = vertebral body.

Article Information

Address reprint requests to: Charles Kuntz IV, M.D., c/o Editorial Office, The Neuroscience Institute, Department of Neurosurgery, ML 0515, 231 Albert Sabin Way, Cincinnati, Ohio 45267-0515. email:

© AANS, except where prohibited by US copyright law.



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    Schematic illustrations of lateral radiographs of the spine from the occiput (O) to the pelvis, demonstrating regional and global neutral upright sagittal spinal alignment. Radiographic sagittal occiput–pelvis angles and displacements are depicted. PI = pelvic incidence; PT = pelvic tilt; SI = sacral inclination; SS = sacral slope.

  • View in gallery

    Schematic illustrations showing clinical measurement of the CBVA. The CBVA is defined as the angle subtended by a vertical reference line and a line parallel to the chin and brow with the neck in neutral or fixed position and the knees and hips extended. A: Normal CBVA. B: The CBVA with a lumbar kyphotic deformity.



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