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C4 constant vertebra: a novel benchmark of physiological cervical sagittal alignment

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Abstract

Background

Cervical sagittal alignment is essential, and there is considerable debate as to what constitutes physiological sagittal alignment. The purpose of this study was to identify constant parameters for characterizing cervical sagittal alignment under physiological conditions.

Methods

A cross-sectional study was conducted in which asymptomatic subjects were recruited to undergo lateral cervical spine radiographs. Each subject was classified according to three authoritative cervical sagittal morphology classifications, followed by the evaluation of variations in radiological parameters across morphotypes. Moreover, the correlations among cervical sagittal parameters, age, and cervicothoracic junction parameters were also investigated.

Results

A total of 183 asymptomatic Chinese subjects were enrolled with a mean age of 48.4 years. Subjects with various cervical sagittal morphologies had comparable C4 endplate slope angles under all three different typing systems. Among patients of different ages, C2–C4 endplate slope angles remained constant. Regarding the cervicothoracic junction parameters, T1 slope and thoracic inlet angle affected cervical sagittal parameters, including cervical lordosis and C2–7 sagittal vertical axis, and were correlated with the endplate slope angles of C5 and below and did not affect the endplate slope angles of C4 and above. In general, the slope of the C4 inferior endplate ranges between 13° and 15° under different physiological conditions.

Conclusions

In the asymptomatic population, the C4 vertebral body maintains a constant slope angle under physiological conditions. The novel concept of C4 as a constant vertebra would provide a vital benchmark for diagnosing pathological sagittal alignment abnormalities and planning the surgical reconstruction of cervical lordosis.

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Funding

There was no financial support for this study.

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Author notes

  1. Haocheng Xu, Zhaoyang Gong and Yong Yang have contributed equally and should be considered co-first authors.

Authors and Affiliations

  1. Department of Orthopedics, Huashan Hospital, Fudan University, 12 Middle Wulumuqi Road, Shanghai, China

    Haocheng Xu, Zhaoyang Gong, Fan Zhang, Fei Zou, Xinlei Xia, Xiaosheng Ma, Feizhou Lyu, Jianyuan Jiang & Hongli Wang

  2. Department of Orthopedics, Shanghai Fifth People’s Hospital, Fudan University, Shanghai, China

    Feizhou Lyu

  3. Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China

    Yong Yang

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  1. Haocheng Xu
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Correspondence to Feizhou Lyu or Hongli Wang.

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The authors have no competing interests to declare that are relevant to the content of this article.

Ethical approval

The current study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki as well as relevant regulations of the US Health Insurance Portability and Accountability Act. Details that might disclose the identity of the subjects under study was omitted. The current study was approved by the ethical committee of Huashan Hospital (KY2022-083).

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Xu, H., Gong, Z., Yang, Y. et al. C4 constant vertebra: a novel benchmark of physiological cervical sagittal alignment. Eur Spine J 33, 1195–1204 (2024). https://doi.org/10.1007/s00586-023-08100-w

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  • DOI: https://doi.org/10.1007/s00586-023-08100-w

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