Basic ScienceCervical lordosis: the effect of age and gender
Introduction
Cervical lordosis is the anterior convexity of the cervical spine from the first thoracic vertebra to the foramen magnum. It is situated at an important intersection between the neural and respiratory systems, the masticatory apparatus, major blood vessels, and endocrine glands. Cervical lordosis is essential for maintaining the head above the thorax in upright posture, enabling a forward gaze.
The degree of lordosis is determined by the orientation of the foramen magnum and by the wedging of the cervical vertebral bodies and intervertebral discs. Dorsal wedging of the vertebral bodies and discs (anterior height greater than posterior height) will increase the amount of cervical lordosis, whereas ventral wedging will decrease it [1], [2], [3].
An appropriate cervical lordosis is essential for efficient mastication function, breathing control, vocal production, and eye movement, and serves as part of the shock-absorbing mechanism during walking and running. Loss of the normal cervical curvature may be associated with pain, temporomandibular joint dysfunction, and other disorders [4], [5], [6].
Cervical lordosis begins development during intrauterine life [7]. It becomes clinically apparent at ages 3–4 months with head-lifting and becomes most pronounced at age 9 months with sitting [8], [9]. Thereafter, lordosis is the more common sagittal profile of the cervical spine [10], [11]. Cervical lordosis normally decreases from age 1 years to 9 years, and increases afterwards in response to increased thoracic kyphosis [12], [13].
Most studies did not find differences in the degree of cervical lordosis between males and females in young and adults [5], [12], [13]. However, Boyle et al. [14] found that in elderly subjects (above 75 years), the cervical lordosis measured between C2 and C7 was higher in females (26 degrees) than in males (12 degrees). Recently, it has been suggested that although the total cervical lordosis between the foramen magnum and C7 of males and females was similar, there are significant gender differences in the upper and lower cervical lordosis [2].
The cervical spine is a complex structure; its flexibility allows a wide range of motion while at the same time it provides stability to bear the weight of the head and maintain horizontal gaze. This complex nature of the cervical region lends it susceptible to a variety of disorders and complications, many of which associate with alignment pathology that may lead to surgical consideration. Cervical malalignment contributes to the pathogenesis of greater cord tension, an increase in intramedullary pressure, myelopathy, and headaches [15], [16]. Maintenance of cervical sagittal balance is reported to help improve symptoms and general health-related quality of life in patients undergoing posterior cervical fusion. Therefore, cervical lordosis values, of the nonpathological population, should be taken into account before any procedures involving cervical stabilization, lordosis correction, and lordosis restoration.
Therefore, the purpose of the present study was to evaluate postural differences in the cervical lordosis between males and females from childhood to adulthood.
Section snippets
Materials and methods
Radiographs of 583 individuals aged 6 to 50 years, obtained between 2010 and 2015, were reviewed. Radiographs were performed to rule out cervical pathology due to motor vehicle accident or other trauma. Inclusion criteria included upright radiograph, visualization of all cervical vertebrae and cranial base, and a true lateral position. Only radiographs with grade 0, according to Kellgren classification for spinal degeneration [17], [18], were included. Exclusion criteria included any
Measurements
On each radiograph, the following lines were drawn (Fig. 1):
Foramen magnum (FM): between the basion and the opisthion
C1: a line crossing the anterior and the posterior arch of the first cervical vertebra
C2: parallel to the inferior end plate of C2
Two lines were drawn for each vertebra (C3–C7); a superior line parallel to the superior end plate and an inferior line parallel to the inferior end plate.
Based on these lines, the following angles were measured by one of the authors (SS):
- •
Total
Results
Younger group average age was 14.4±3.5 years, and that of boys and girls was similar (p=.65). The average age of the adults was 31.3±8.1 years and that of males and females was similar (p=.97, Table 1).
Children had a total cervical lordosis (FM–C7) of 39.6±10.0° (Table 1, Fig. 2), resulting from the highly lordotic cervical lordosis (C1–C7, 50.7±10.5°) and the kyphotic FM–C1 angle (−9.8±7.3°). The upper cervical lordosis (FM–C3) contributed 25.9±9.1° to the total lordosis and the lower cervical
Discussion
In the present study, we explored age and gender differences in cervical spine architecture, with the purpose of establishing normative data for the alignment of the cervical lordosis. Although there are many reports describing the architecture of the cervical lordosis, to the best of our knowledge no recent data exist on wedging of the intervertebral discs and vertebral bodies in the pediatric population. In addition, very few studies have explored gender differences from childhood to
Conclusions
The interaction between malalignment of the cervical lordosis with pain, disability, and health-related quality of life is well established. Patients with poor cervical lordosis suffer from headaches, neck and shoulder pain, mastication problems, and greater energy expenditure to maintain upright posture. Understanding the architecture of the cervical spine is important to identify sagittal imbalance and to establish correct alignment of the cervical lordosis.
In the present study, we showed
References (35)
- et al.
The use of the T1 sagittal angle in predicting overall sagittal balance of the spine
Spine J
(2010) - et al.
Influence of age on cervicothoracic spinal curvature: an ex vivo radiographic survey
Clin Biomech (Bristol, Avon)
(2002) - et al.
An evaluation of head position and craniofacial reference line variation
HOMO-Journal of Comparative Human Biology
(2009) - et al.
Lumbar lordosis
Spine J
(2014) - et al.
Experimental manipulation of head posture
Am J Orthod
(1980) - et al.
Foramen magnum orientation and its association with cervical lordosis: a model for reconstructing cervical curvature in archeological and extinct hominin specimens
Advances Anthropol
(2014) - et al.
Is it possible to evaluate the parameters of cervical sagittal alignment on cervical computed tomographic scans?
Spine
(2014) - et al.
Modeling of the sagittal cervical spine as a method to discriminate hypolordosis: results of elliptical and circular modeling in 72 asymptomatic subjects, 52 acute neck pain subjects, and 70 chronic neck pain subjects
Spine
(2004) - et al.
Cervical spine curvature and craniofacial morphology in an adult Caucasian group: a multiple regression analysis
Eur J Orthodon
(2007) - et al.
The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery
Neurosurgery
(2012)
A radiographic study of the human fetal spine. The development of the secondary cervical curvature
J Anat
Differential diagnose der halswirbelverletzungen im kindesalter
Fortshr Roentgen Str
Basic and clinical anatomy of the spine, spinal cord and ANS
The normal cervical lordosis
Radiology
Roentgenographic findings of the cervical spine in asymptomatic people
Spine
Roentgenographic variations in the normal cervical spine
Radiology
Growth of the cervical spine with special reference to its lordosis and mobility
Spine
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Author disclosures: EB: Nothing to disclose. SS: Nothing to disclose. MS: Nothing to disclose.